Provider Demographics
NPI:1639325962
Name:SUN LAKE OPTICAL
Entity Type:Organization
Organization Name:SUN LAKE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETELIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:480-895-8900
Mailing Address - Street 1:25237 S SUN LAKES BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:SUN LAKES
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-6467
Mailing Address - Country:US
Mailing Address - Phone:480-895-8900
Mailing Address - Fax:480-895-5657
Practice Address - Street 1:25237 S SUN LAKES BLVD STE 1
Practice Address - Street 2:
Practice Address - City:SUN LAKES
Practice Address - State:AZ
Practice Address - Zip Code:85248-6467
Practice Address - Country:US
Practice Address - Phone:480-895-8900
Practice Address - Fax:480-895-5657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies