Provider Demographics
NPI:1497928725
Name:CULLMAN OPTICAL SHOP INC
Entity Type:Organization
Organization Name:CULLMAN OPTICAL SHOP INC
Other - Org Name:CULLMAN OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:LAY
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICAN
Authorized Official - Phone:256-739-3651
Mailing Address - Street 1:115 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-2903
Mailing Address - Country:US
Mailing Address - Phone:256-739-3651
Mailing Address - Fax:
Practice Address - Street 1:115 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:CULLMAN
Practice Address - State:AL
Practice Address - Zip Code:35055-2903
Practice Address - Country:US
Practice Address - Phone:256-739-3651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALNOT REQUIRED IN AL156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1248830001Medicare NSC