Provider Demographics
NPI:1437812047
Name:THIRD COAST OPTICAL, LLC
Entity Type:Organization
Organization Name:THIRD COAST OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-923-8684
Mailing Address - Street 1:22835 STATE HIGHWAY 59 S STE D
Mailing Address - Street 2:
Mailing Address - City:ROBERTSDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36567-6154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22835 STATE HIGHWAY 59 S STE D
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-6154
Practice Address - Country:US
Practice Address - Phone:251-923-8684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center