Provider Demographics
NPI:1013903962
Name:TRISTATE OPTICAL, INC.
Entity type:Organization
Organization Name:TRISTATE OPTICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-436-2020
Mailing Address - Street 1:6424 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6204
Mailing Address - Country:US
Mailing Address - Phone:260-436-2020
Mailing Address - Fax:260-436-7628
Practice Address - Street 1:6424 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-6204
Practice Address - Country:US
Practice Address - Phone:260-436-2020
Practice Address - Fax:260-436-7628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0480880004Medicare ID - Type UnspecifiedRETAIL OPTICAL