Provider Demographics
NPI:1770630527
Name:PRISM OPTICAL OF ALASKA, INC.
Entity Type:Organization
Organization Name:PRISM OPTICAL OF ALASKA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:GITLAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-754-5894
Mailing Address - Street 1:10954 NW 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33168-2108
Mailing Address - Country:US
Mailing Address - Phone:305-754-5894
Mailing Address - Fax:
Practice Address - Street 1:1515 E TUDOR RD
Practice Address - Street 2:SUITE 5
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-1036
Practice Address - Country:US
Practice Address - Phone:907-770-7747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK178332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies