Provider Demographics
NPI:1245622703
Name:MR MIKES 39.95 OPTICAL L.L.C.
Entity type:Organization
Organization Name:MR MIKES 39.95 OPTICAL L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:
Authorized Official - Last Name:YUCHNITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-859-9826
Mailing Address - Street 1:5755 N.W.LOOP 410
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238
Mailing Address - Country:US
Mailing Address - Phone:210-859-9826
Mailing Address - Fax:210-257-8466
Practice Address - Street 1:5755 NW LOOP 410
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78238-2502
Practice Address - Country:US
Practice Address - Phone:210-656-3995
Practice Address - Fax:210-257-8466
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MR MIKES 39.95 OPTICAL L.L.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies