Provider Demographics
NPI:1891969804
Name:STANLEYS CUSTOM EYEWEAR INC
Entity Type:Organization
Organization Name:STANLEYS CUSTOM EYEWEAR INC
Other - Org Name:STANLEY'S CUSTOM EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED OPTICIAN
Authorized Official - Phone:941-351-7744
Mailing Address - Street 1:6380 N LOCKWOOD RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34243-2531
Mailing Address - Country:US
Mailing Address - Phone:941-351-7744
Mailing Address - Fax:941-351-9839
Practice Address - Street 1:6380 N LOCKWOOD RIDGE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34243-2531
Practice Address - Country:US
Practice Address - Phone:941-351-7744
Practice Address - Fax:941-351-9839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2760156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1064610001Medicare NSC