Provider Demographics
NPI:1922252766
Name:SAM'S OPTICAL, OKLAHOMA CITY, LLC
Entity Type:Organization
Organization Name:SAM'S OPTICAL, OKLAHOMA CITY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-631-7560
Mailing Address - Street 1:1078D CROSSROADS MALL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73149
Mailing Address - Country:US
Mailing Address - Phone:405-631-7560
Mailing Address - Fax:
Practice Address - Street 1:1078D CROSSROADS MALL
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73149
Practice Address - Country:US
Practice Address - Phone:405-631-7560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty