Provider Demographics
NPI:1487031233
Name:OPTIKK 30A, PA
Entity Type:Organization
Organization Name:OPTIKK 30A, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KORRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:LALIM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-608-3135
Mailing Address - Street 1:2050 HWY 30A
Mailing Address - Street 2:M 1-119
Mailing Address - City:SANTA ROSA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2050 W COUNTY HIGHWAY 30A
Practice Address - Street 2:M1-119
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-0187
Practice Address - Country:US
Practice Address - Phone:850-608-3135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3910152W00000X
FLOPC3910332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty