Provider Demographics
NPI:1619155736
Name:EAST MONTGOMERY OPTICAL SHOPPE
Entity Type:Organization
Organization Name:EAST MONTGOMERY OPTICAL SHOPPE
Other - Org Name:WETUMPKA OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:GUINN
Authorized Official - Last Name:PAULK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-260-8511
Mailing Address - Street 1:262 MITYLENE PARK DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-3548
Mailing Address - Country:US
Mailing Address - Phone:334-260-8511
Mailing Address - Fax:334-260-8755
Practice Address - Street 1:262 MITYLENE PARK DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3548
Practice Address - Country:US
Practice Address - Phone:334-260-8511
Practice Address - Fax:334-260-8755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-31
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL332H00000X332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51515037OtherBCBS