Provider Demographics
NPI:1689941411
Name:OPTIC GALLERY SAHARA LLC
Entity Type:Organization
Organization Name:OPTIC GALLERY SAHARA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:PAEZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-893-3937
Mailing Address - Street 1:2580 S DECATUR BLVD STE 6
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-5513
Mailing Address - Country:US
Mailing Address - Phone:702-893-3937
Mailing Address - Fax:702-893-3429
Practice Address - Street 1:2580 S DECATUR BLVD STE 6
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-5513
Practice Address - Country:US
Practice Address - Phone:702-893-3937
Practice Address - Fax:702-893-3429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV507152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100506828Medicaid
NVV40532Medicare PIN