Provider Demographics
NPI:1649485483
Name:SG OPTICAL LLC
Entity type:Organization
Organization Name:SG OPTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:FERICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-738-6727
Mailing Address - Street 1:1657 MOUNTAIN CITY HIGHWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-2459
Mailing Address - Country:US
Mailing Address - Phone:775-738-6727
Mailing Address - Fax:775-753-6452
Practice Address - Street 1:1657 MOUNTAIN CITY HIGHWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-2459
Practice Address - Country:US
Practice Address - Phone:775-738-6727
Practice Address - Fax:775-753-6452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV524152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1594137Medicare UPIN