Provider Demographics
NPI:1487660221
Name:OPTICAL SHOPPE PLLC
Entity Type:Organization
Organization Name:OPTICAL SHOPPE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-484-0101
Mailing Address - Street 1:3206 CHURCHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5206
Mailing Address - Country:US
Mailing Address - Phone:757-484-0303
Mailing Address - Fax:757-484-0515
Practice Address - Street 1:3206 CHURCHLAND BLVD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-5206
Practice Address - Country:US
Practice Address - Phone:757-484-0303
Practice Address - Fax:757-484-0515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA6005389332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA248303OtherANTHEM
VA010080371Medicaid
H50094Medicare UPIN
VA248303OtherANTHEM