Provider Demographics
NPI:1679805642
Name:BEST OPTICAL LLC
Entity Type:Organization
Organization Name:BEST OPTICAL LLC
Other - Org Name:MEMMEN OPTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-380-0100
Mailing Address - Street 1:1543 PARK PL
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-1970
Mailing Address - Country:US
Mailing Address - Phone:920-497-0100
Mailing Address - Fax:920-497-0101
Practice Address - Street 1:1543 PARK PL
Practice Address - Street 2:SUITE 400
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-1970
Practice Address - Country:US
Practice Address - Phone:920-497-0100
Practice Address - Fax:920-497-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-02
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI29183020174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31395200Medicaid
WI000140026Medicare PIN
WI31395200Medicaid