Provider Demographics
NPI:1740069772
Name:DE LA CRUZ OPTICAL LLC
Entity type:Organization
Organization Name:DE LA CRUZ OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:OLSOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:360-660-5496
Mailing Address - Street 1:PO BOX 1875
Mailing Address - Street 2:
Mailing Address - City:OCEAN SHORES
Mailing Address - State:WA
Mailing Address - Zip Code:98569-1875
Mailing Address - Country:US
Mailing Address - Phone:360-660-5496
Mailing Address - Fax:
Practice Address - Street 1:3755 AIRPORT WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4610
Practice Address - Country:US
Practice Address - Phone:360-474-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty