Provider Demographics
NPI:1356459762
Name:OPTICAL LABORATORY LLC
Entity Type:Organization
Organization Name:OPTICAL LABORATORY LLC
Other - Org Name:PINKOSON HAZOURI OPTICAL LABORATORY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARJORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZOURI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-376-5563
Mailing Address - Street 1:618 SW 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32601
Mailing Address - Country:US
Mailing Address - Phone:352-376-5563
Mailing Address - Fax:352-376-8783
Practice Address - Street 1:618 SW 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601
Practice Address - Country:US
Practice Address - Phone:352-376-5563
Practice Address - Fax:352-376-8783
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE0000362156FX1800X
FL29463332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0841690001Medicare NSC