Provider Demographics
NPI:1710148671
Name:OPTICAL EXPRESS OF CRYSTAL RIVER INC
Entity Type:Organization
Organization Name:OPTICAL EXPRESS OF CRYSTAL RIVER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MCFALL FIALKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-795-2020
Mailing Address - Street 1:1801 NW US HIGHWAY 19
Mailing Address - Street 2:SUITE 165
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34428-6133
Mailing Address - Country:US
Mailing Address - Phone:352-795-2020
Mailing Address - Fax:352-795-7432
Practice Address - Street 1:1801 NW US HWY 19
Practice Address - Street 2:SUITE 165
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34428-6119
Practice Address - Country:US
Practice Address - Phone:352-795-2020
Practice Address - Fax:352-795-7432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6067100001Medicare NSC