Provider Demographics
NPI:1386814432
Name:SAM'S CROSSROADS OPTICAL
Entity Type:Organization
Organization Name:SAM'S CROSSROADS OPTICAL
Other - Org Name:SAM'S OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTICAN
Authorized Official - Prefix:
Authorized Official - First Name:SAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-631-7558
Mailing Address - Street 1:1078 CROSSROADS MALL
Mailing Address - Street 2:STE D
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73149-4202
Mailing Address - Country:US
Mailing Address - Phone:405-631-7558
Mailing Address - Fax:
Practice Address - Street 1:1078 CROSSROADS MALL
Practice Address - Street 2:STE D
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73149-4202
Practice Address - Country:US
Practice Address - Phone:405-631-7558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-05
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0725590001Medicare NSC