Provider Demographics
NPI:1407954399
Name:MASTERCRAFT OPTICAL GALLERY, INC.
Entity Type:Organization
Organization Name:MASTERCRAFT OPTICAL GALLERY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:863-763-4334
Mailing Address - Street 1:520 S PARROTT AVE
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-4345
Mailing Address - Country:US
Mailing Address - Phone:863-763-4334
Mailing Address - Fax:863-763-3226
Practice Address - Street 1:520 S PARROTT AVE
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-4345
Practice Address - Country:US
Practice Address - Phone:863-763-4334
Practice Address - Fax:863-763-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD02342332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD7841OtherBLUE CROSS BLUE SHIELD
FL086132400Medicaid
FLD7841OtherBLUE CROSS BLUE SHIELD