Provider Demographics
NPI:1396835690
Name:OPTICAL SPECIALISTS,INC
Entity Type:Organization
Organization Name:OPTICAL SPECIALISTS,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-726-6625
Mailing Address - Street 1:950 FRANCIS PL
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-2465
Mailing Address - Country:US
Mailing Address - Phone:314-726-6625
Mailing Address - Fax:314-725-2830
Practice Address - Street 1:950 FRANCIS PL
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-2465
Practice Address - Country:US
Practice Address - Phone:314-726-6625
Practice Address - Fax:314-725-2830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-15
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO6032020001Medicare NSC