Provider Demographics
NPI:1881862811
Name:GARYS CUSTOM OPTIK INC
Entity Type:Organization
Organization Name:GARYS CUSTOM OPTIK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:FIEBIG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-701-5367
Mailing Address - Street 1:8354 RESEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-4619
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8354 RESEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324-4619
Practice Address - Country:US
Practice Address - Phone:818-701-5367
Practice Address - Fax:818-886-0545
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ82127ZMedicaid
CAZZZ82127ZMedicaid