Provider Demographics
NPI:1598858300
Name:LARRY L. MINIX DBA THE OPTICAL SHOPPE
Entity Type:Organization
Organization Name:LARRY L. MINIX DBA THE OPTICAL SHOPPE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MINIX
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN HIS
Authorized Official - Phone:270-926-4933
Mailing Address - Street 1:1115 TAMARACK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6984
Mailing Address - Country:US
Mailing Address - Phone:270-926-4933
Mailing Address - Fax:270-688-0627
Practice Address - Street 1:1115 TAMARACK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6984
Practice Address - Country:US
Practice Address - Phone:270-926-4933
Practice Address - Fax:270-688-0627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument SpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY52800315Medicaid
KY52903945Medicaid
KY52800315Medicaid