Provider Demographics
NPI:1598499519
Name:SUPERIOR OPTICAL LABS, INC
Entity Type:Organization
Organization Name:SUPERIOR OPTICAL LABS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:BODART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-928-5743
Mailing Address - Street 1:6525 SUNPLEX DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-8704
Mailing Address - Country:US
Mailing Address - Phone:228-875-3796
Mailing Address - Fax:
Practice Address - Street 1:6525 SUNPLEX DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-8704
Practice Address - Country:US
Practice Address - Phone:228-875-3796
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier