Provider Demographics
NPI:1598213209
Name:CHANNELSIDE OPTICAL LLC
Entity Type:Organization
Organization Name:CHANNELSIDE OPTICAL LLC
Other - Org Name:OPES OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DISPENSING OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:SARA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:813-906-6737
Mailing Address - Street 1:912 CHANNELSIDE DR
Mailing Address - Street 2:SUITE 2102
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-4229
Mailing Address - Country:US
Mailing Address - Phone:813-906-6737
Mailing Address - Fax:855-916-6737
Practice Address - Street 1:912 CHANNELSIDE DR
Practice Address - Street 2:SUITE 2102
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4229
Practice Address - Country:US
Practice Address - Phone:813-906-6737
Practice Address - Fax:855-916-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE2231332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier