Provider Demographics
NPI:1861639080
Name:SAM'S OPTICAL, PENN SQUARE, LLC
Entity Type:Organization
Organization Name:SAM'S OPTICAL, PENN SQUARE, LLC
Other - Org Name:SAM'S OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-631-7558
Mailing Address - Street 1:1900 NW EXPRESSWAY STE R1-114
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73118-1802
Mailing Address - Country:US
Mailing Address - Phone:405-631-7558
Mailing Address - Fax:405-631-0615
Practice Address - Street 1:1900 NW EXPRESSWAY STE R1-114
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-1802
Practice Address - Country:US
Practice Address - Phone:405-631-7558
Practice Address - Fax:405-631-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-09
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty