Provider Demographics
NPI:1497779045
Name:STATE STREET OPTICAL, INC.
Entity Type:Organization
Organization Name:STATE STREET OPTICAL, INC.
Other - Org Name:LAMMERS OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:PAYNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-222-0281
Mailing Address - Street 1:1118 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2810
Mailing Address - Country:US
Mailing Address - Phone:217-222-0281
Mailing Address - Fax:217-222-0281
Practice Address - Street 1:1118 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2810
Practice Address - Country:US
Practice Address - Phone:217-222-0281
Practice Address - Fax:217-222-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251-3787332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0714080001Medicare ID - Type Unspecified