Provider Demographics
NPI:1669644043
Name:MAIN OPTICAL
Entity Type:Organization
Organization Name:MAIN OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:L
Authorized Official - Last Name:FRANK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-773-8023
Mailing Address - Street 1:400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-2318
Mailing Address - Country:US
Mailing Address - Phone:937-773-8023
Mailing Address - Fax:
Practice Address - Street 1:400 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-2318
Practice Address - Country:US
Practice Address - Phone:937-773-8023
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-26
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4713S332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5173900001Medicare NSC