Provider Demographics
NPI:1851930879
Name:MIC OPTICAL SOURCING,INC.
Entity Type:Organization
Organization Name:MIC OPTICAL SOURCING,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GANG
Authorized Official - Middle Name:
Authorized Official - Last Name:HE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:720-238-2922
Mailing Address - Street 1:2200 W ALAMEDA AVE UNIT 16
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80223-1947
Mailing Address - Country:US
Mailing Address - Phone:720-238-2922
Mailing Address - Fax:720-572-7999
Practice Address - Street 1:2200 W ALAMEDA AVE UNIT 16
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80223-1947
Practice Address - Country:US
Practice Address - Phone:720-238-2922
Practice Address - Fax:720-572-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-23
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty