Provider Demographics
NPI:1720294713
Name:MIYAGI ISLAND OPTICAL INC
Entity Type:Organization
Organization Name:MIYAGI ISLAND OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIYAGISHIMA
Authorized Official - Suffix:
Authorized Official - Credentials:BS AA FNAD
Authorized Official - Phone:505-434-0036
Mailing Address - Street 1:910 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310
Mailing Address - Country:US
Mailing Address - Phone:505-434-0036
Mailing Address - Fax:505-434-0036
Practice Address - Street 1:910 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310
Practice Address - Country:US
Practice Address - Phone:505-434-0036
Practice Address - Fax:505-434-0036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CERTIFICATE00750332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier