Provider Demographics
NPI:1659637536
Name:THE OPTICAL SHOP
Entity Type:Organization
Organization Name:THE OPTICAL SHOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:BARTLETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-358-8223
Mailing Address - Street 1:2516 SAMARITAN DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4108
Mailing Address - Country:US
Mailing Address - Phone:408-358-8223
Mailing Address - Fax:
Practice Address - Street 1:2516 SAMARITAN DR
Practice Address - Street 2:SUITE E
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4108
Practice Address - Country:US
Practice Address - Phone:408-358-8223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASL6311156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty