Provider Demographics
NPI:1942477476
Name:INNOVATIVE OPTIQUE
Entity Type:Organization
Organization Name:INNOVATIVE OPTIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GUADALUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUILAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-228-9873
Mailing Address - Street 1:333 W BROWN DEER RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-2372
Mailing Address - Country:US
Mailing Address - Phone:414-228-9873
Mailing Address - Fax:414-228-9841
Practice Address - Street 1:333 W BROWN DEER RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53217-2372
Practice Address - Country:US
Practice Address - Phone:414-228-9873
Practice Address - Fax:414-228-9841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier