Provider Demographics
NPI:1285056200
Name:MR MIKES 3995 OPTICAL LLC
Entity type:Organization
Organization Name:MR MIKES 3995 OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NOAH
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:YUCHNITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-656-3995
Mailing Address - Street 1:5755 NW LOOP 410
Mailing Address - Street 2:STE. 105
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-2502
Mailing Address - Country:US
Mailing Address - Phone:210-656-3995
Mailing Address - Fax:
Practice Address - Street 1:5755 NW LOOP 410
Practice Address - Street 2:STE. 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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier