Provider Demographics
NPI:1548385818
Name:POTOSI OPTOMETRIC CENTER
Entity Type:Organization
Organization Name:POTOSI OPTOMETRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PREISENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ORIE
Authorized Official - Last Name:ALBERT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-438-3415
Mailing Address - Street 1:307 N MISSOURI ST
Mailing Address - Street 2:PO BOX 217
Mailing Address - City:POTOSI
Mailing Address - State:MO
Mailing Address - Zip Code:63664-1747
Mailing Address - Country:US
Mailing Address - Phone:573-438-3415
Mailing Address - Fax:573-438-7667
Practice Address - Street 1:307 N MISSOURI ST
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1747
Practice Address - Country:US
Practice Address - Phone:573-438-3415
Practice Address - Fax:573-438-7667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02120332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOT92302Medicare UPIN