Provider Demographics
NPI:1851675003
Name:LICATA OPTICAL LLC
Entity Type:Organization
Organization Name:LICATA OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:LICATA
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:480-632-5075
Mailing Address - Street 1:2048 E BASELINE RD
Mailing Address - Street 2:C-6
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-6969
Mailing Address - Country:US
Mailing Address - Phone:480-632-5075
Mailing Address - Fax:480-507-0836
Practice Address - Street 1:2048 E BASELINE RD
Practice Address - Street 2:C-6
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6969
Practice Address - Country:US
Practice Address - Phone:480-632-5075
Practice Address - Fax:480-507-0836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1185E332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier