Provider Demographics
NPI:1518575513
Name:OPTICAL GALLERIA PLLC
Entity Type:Organization
Organization Name:OPTICAL GALLERIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-270-8170
Mailing Address - Street 1:4135 DR MARTIN LUTHER KING BLVD # G16
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-4809
Mailing Address - Country:US
Mailing Address - Phone:239-313-5259
Mailing Address - Fax:239-672-4368
Practice Address - Street 1:4135 DR MARTIN LUTHER KING BLVD # G16
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-4809
Practice Address - Country:US
Practice Address - Phone:239-313-5259
Practice Address - Fax:239-672-4368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty