Provider Demographics
NPI:1689023723
Name:OPTICAL SHOPPE INC
Entity Type:Organization
Organization Name:OPTICAL SHOPPE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:PAUMEN
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:970-565-1580
Mailing Address - Street 1:48 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CORTEZ
Mailing Address - State:CO
Mailing Address - Zip Code:81321-3209
Mailing Address - Country:US
Mailing Address - Phone:970-565-1580
Mailing Address - Fax:970-565-8203
Practice Address - Street 1:48 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CORTEZ
Practice Address - State:CO
Practice Address - Zip Code:81321-3209
Practice Address - Country:US
Practice Address - Phone:970-565-1580
Practice Address - Fax:970-565-8203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08-003899Medicaid