Provider Demographics
NPI:1891896932
Name:SOUTH TULSA OPTICAL, INC.
Entity Type:Organization
Organization Name:SOUTH TULSA OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAINER
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC
Authorized Official - Phone:918-494-0351
Mailing Address - Street 1:7171 S YALE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7171 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6374
Practice Address - Country:US
Practice Address - Phone:918-494-0351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK112361OtherEYEMED
OK=========001OtherBCBSOK
OK112361OtherEYEMED