Provider Demographics
NPI:1639225493
Name:OPTICAL EAST INC
Entity Type:Organization
Organization Name:OPTICAL EAST INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:RAKOWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:480-830-1292
Mailing Address - Street 1:4419 E MAIN #109
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205
Mailing Address - Country:US
Mailing Address - Phone:480-830-1292
Mailing Address - Fax:480-924-9042
Practice Address - Street 1:4419 E MAIN ST STE 109
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-7900
Practice Address - Country:US
Practice Address - Phone:480-830-1292
Practice Address - Fax:480-924-9042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ299156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4765020001Medicare NSC