Provider Demographics
NPI:1457961096
Name:CANYON LAKE OPTICAL LLC
Entity Type:Organization
Organization Name:CANYON LAKE OPTICAL LLC
Other - Org Name:CANYON LAKE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LADD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:830-522-4069
Mailing Address - Street 1:1387 SATTLER RD UNIT A
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78132-2306
Mailing Address - Country:US
Mailing Address - Phone:830-964-2332
Mailing Address - Fax:866-772-0758
Practice Address - Street 1:1387 SATTLER RD
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-2305
Practice Address - Country:US
Practice Address - Phone:830-964-2332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EYETOPIA OPTICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-07
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier