Provider Demographics
NPI:1962683557
Name:MIRACLE VISION OPTICAL
Entity Type:Organization
Organization Name:MIRACLE VISION OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:ADRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTANEDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-337-5843
Mailing Address - Street 1:4042 MIHO
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78223-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4042 MIHO
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3822
Practice Address - Country:US
Practice Address - Phone:210-337-5243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-24
Last Update Date:2007-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDR4082332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier