Provider Demographics
NPI:1528223302
Name:PREFERRED OPTICAL
Entity Type:Organization
Organization Name:PREFERRED OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETHGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-481-2700
Mailing Address - Street 1:6606 S YALE
Mailing Address - Street 2:#201
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136
Mailing Address - Country:US
Mailing Address - Phone:918-481-2700
Mailing Address - Fax:918-492-7451
Practice Address - Street 1:6606 S YALE
Practice Address - Street 2:#201
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136
Practice Address - Country:US
Practice Address - Phone:918-481-2700
Practice Address - Fax:918-492-7451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-22
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1036970001Medicare NSC