Provider Demographics
NPI:1942537089
Name:SACKS OPTICAL BOUTIQUE, LLC
Entity Type:Organization
Organization Name:SACKS OPTICAL BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SACKS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-275-1676
Mailing Address - Street 1:1125 S BEVERLY DR
Mailing Address - Street 2:710
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-1148
Mailing Address - Country:US
Mailing Address - Phone:310-275-1676
Mailing Address - Fax:
Practice Address - Street 1:1125 S BEVERLY DR
Practice Address - Street 2:710
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1148
Practice Address - Country:US
Practice Address - Phone:310-275-1676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG64460332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6328250001Medicare NSC