Provider Demographics
NPI:1689852535
Name:YOUNG OPTICAL
Entity Type:Organization
Organization Name:YOUNG OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-883-3051
Mailing Address - Street 1:PO BOX 80
Mailing Address - Street 2:
Mailing Address - City:MARLIN
Mailing Address - State:TX
Mailing Address - Zip Code:76661-0080
Mailing Address - Country:US
Mailing Address - Phone:254-883-3051
Mailing Address - Fax:254-803-3484
Practice Address - Street 1:226 COLEMAN
Practice Address - Street 2:STE 103
Practice Address - City:MARLIN
Practice Address - State:TX
Practice Address - Zip Code:76661
Practice Address - Country:US
Practice Address - Phone:254-883-3051
Practice Address - Fax:254-803-3487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-02
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX156FX1201X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1201XEye and Vision Services ProvidersTechnician/TechnologistOptometric AssistantGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX066494801Medicaid
TX3052350001Medicare NSC
TX066494801Medicaid