Provider Demographics
NPI:1407998891
Name:PRO OPTICS EYEWEAR CORP
Entity Type:Organization
Organization Name:PRO OPTICS EYEWEAR CORP
Other - Org Name:SITE FOR SORE EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LINN
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:LAI
Authorized Official - Suffix:
Authorized Official - Credentials:RDO
Authorized Official - Phone:408-288-5037
Mailing Address - Street 1:1111 STORY RD
Mailing Address - Street 2:SUITE 1079
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122
Mailing Address - Country:US
Mailing Address - Phone:408-288-5037
Mailing Address - Fax:408-288-9265
Practice Address - Street 1:1111 STORY RD
Practice Address - Street 2:SUITE 1079 GRAND CENTURY MALL
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122
Practice Address - Country:US
Practice Address - Phone:408-288-5037
Practice Address - Fax:408-288-9265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD7234156FX1800X
CAD7165332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5595020001Medicare ID - Type Unspecified