Provider Demographics
NPI:1578589107
Name:MAYNOR & MITCHELL OPTICAL SHOP LLC
Entity Type:Organization
Organization Name:MAYNOR & MITCHELL OPTICAL SHOP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:N
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-533-0315
Mailing Address - Street 1:3501 MEMORIAL PKWY SW STE 200
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6901
Mailing Address - Country:US
Mailing Address - Phone:256-533-0315
Mailing Address - Fax:256-536-0360
Practice Address - Street 1:3501 MEMORIAL PKWY SW STE 200
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6901
Practice Address - Country:US
Practice Address - Phone:256-533-0315
Practice Address - Fax:256-536-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL332H00000X
ALMD21789332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51511477OtherBCBS PROVIDER NUMBER
AL529916870Medicaid
AL529916870Medicaid