Provider Demographics
NPI:1659759918
Name:OLDE TYME OPTICAL
Entity Type:Organization
Organization Name:OLDE TYME OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ANTONE
Authorized Official - Last Name:BLISSENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-274-2020
Mailing Address - Street 1:100 N. 8TH ST E.
Mailing Address - Street 2:SUITE 264
Mailing Address - City:E. ST. LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N. 8TH ST E.
Practice Address - Street 2:SUITE 264
Practice Address - City:E. ST. LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62201
Practice Address - Country:US
Practice Address - Phone:618-274-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLDE TYME OPTICAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-07
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid