Provider Demographics
NPI:1932300662
Name:CUSTOM OPTICAL, INC.
Entity Type:Organization
Organization Name:CUSTOM OPTICAL, INC.
Other - Org Name:CUSTOM EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:970-668-0122
Mailing Address - Street 1:PO BOX 583
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-0583
Mailing Address - Country:US
Mailing Address - Phone:970-668-0122
Mailing Address - Fax:970-668-0639
Practice Address - Street 1:842 NORTH SUMMIT BLVD
Practice Address - Street 2:UNIT 28
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-0122
Practice Address - Fax:970-668-0639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1498152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty