Provider Demographics
NPI:1396781829
Name:20/20 OPTICAL, LLC
Entity type:Organization
Organization Name:20/20 OPTICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETIST/OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMEENA
Authorized Official - Middle Name:SULTANA
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-825-2625
Mailing Address - Street 1:329 CARR MANOR CT
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3304
Mailing Address - Country:US
Mailing Address - Phone:636-527-4097
Mailing Address - Fax:
Practice Address - Street 1:2952 DOUGHERTY FERRY RD
Practice Address - Street 2:
Practice Address - City:KIRKWOOD
Practice Address - State:MO
Practice Address - Zip Code:63122-3366
Practice Address - Country:US
Practice Address - Phone:636-825-2625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2009-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA 1762Medicare PIN