Provider Demographics
NPI:1740209691
Name:OPTIC GALLERY
Entity Type:Organization
Organization Name:OPTIC GALLERY
Other - Org Name:DR YOUNGS OFFICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:702-240-2121
Mailing Address - Street 1:2146 ORCHARD MIST ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-1562
Mailing Address - Country:US
Mailing Address - Phone:702-869-4588
Mailing Address - Fax:
Practice Address - Street 1:1930 VILLAGE CENTER CIR STE 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-6238
Practice Address - Country:US
Practice Address - Phone:702-240-2121
Practice Address - Fax:702-240-5858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV328302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV=========Medicare UPIN
NVV34322Medicare ID - Type Unspecified