Provider Demographics
NPI:1396217931
Name:OPTIC SHOP, LLC.
Entity Type:Organization
Organization Name:OPTIC SHOP, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HEATH
Authorized Official - Middle Name:V
Authorized Official - Last Name:HAFFENER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:620-252-8047
Mailing Address - Street 1:2205 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-2936
Mailing Address - Country:US
Mailing Address - Phone:620-251-0050
Mailing Address - Fax:620-688-6055
Practice Address - Street 1:2205 W 8TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-2936
Practice Address - Country:US
Practice Address - Phone:620-251-0050
Practice Address - Fax:620-688-6055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-20
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier