Provider Demographics
NPI:1356005961
Name:COFFEYVILLE OPTIC SHOP LLC
Entity Type:Organization
Organization Name:COFFEYVILLE OPTIC SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-870-4511
Mailing Address - Street 1:4573 CR 2875
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-7962
Mailing Address - Country:US
Mailing Address - Phone:620-870-4511
Mailing Address - Fax:
Practice Address - Street 1:2205 W 8TH ST STE B
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-2950
Practice Address - Country:US
Practice Address - Phone:620-251-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty