Provider Demographics
NPI:1598972077
Name:SHETTLE OPTICAL SOLUTIONS,INC.
Entity Type:Organization
Organization Name:SHETTLE OPTICAL SOLUTIONS,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SHETTLE
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:727-586-1260
Mailing Address - Street 1:670 CLEARWATER LARGO RD N STE B
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33770-2377
Mailing Address - Country:US
Mailing Address - Phone:727-586-1260
Mailing Address - Fax:727-586-3636
Practice Address - Street 1:670 CLEARWATER LARGO RD N STE B
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33770-2377
Practice Address - Country:US
Practice Address - Phone:727-586-1260
Practice Address - Fax:727-586-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3278332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU75249Medicare UPIN
FL4348010001Medicare NSC