Provider Demographics
NPI:1497926349
Name:EAGLE OPTICAL INC
Entity Type:Organization
Organization Name:EAGLE OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:541-523-2020
Mailing Address - Street 1:3705 MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1456
Mailing Address - Country:US
Mailing Address - Phone:541-523-2020
Mailing Address - Fax:541-523-4965
Practice Address - Street 1:3705 MIDWAY DR
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1456
Practice Address - Country:US
Practice Address - Phone:541-523-2020
Practice Address - Fax:541-523-4965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR279170Medicaid
OR279170Medicaid