Provider Demographics
NPI:1679643100
Name:F & G OPTICAL INC
Entity Type:Organization
Organization Name:F & G OPTICAL INC
Other - Org Name:LATHAM OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-476-4185
Mailing Address - Street 1:852 LAKE ST E
Mailing Address - Street 2:UNIT A
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4526
Mailing Address - Country:US
Mailing Address - Phone:952-476-4185
Mailing Address - Fax:952-476-8812
Practice Address - Street 1:852 LAKE ST E
Practice Address - Street 2:UNIT A
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4523
Practice Address - Country:US
Practice Address - Phone:952-476-4185
Practice Address - Fax:952-476-8812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2439152W00000X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN808862400Medicaid
MN5274110001Medicare NSC