Provider Demographics
NPI:1649333451
Name:OPTIQUE PROFESSIONAL EYE CARE, PLLC
Entity type:Organization
Organization Name:OPTIQUE PROFESSIONAL EYE CARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:ANN RAHME
Authorized Official - Last Name:FAIRCHILD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-743-9918
Mailing Address - Street 1:3338 E 51ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-3512
Mailing Address - Country:US
Mailing Address - Phone:918-743-9918
Mailing Address - Fax:918-743-9919
Practice Address - Street 1:3338 E 51ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-3512
Practice Address - Country:US
Practice Address - Phone:918-743-9918
Practice Address - Fax:918-743-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2348152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OPTQ27621OtherSPECTERA
OK2348OtherEYEMED
19826OtherNVA
OK100765750AMedicaid
OPTQ27621OtherSPECTERA
OK100765750AMedicaid
5621750001Medicare NSC