Provider Demographics
NPI:1770840514
Name:COLISEUM EYEWEAR
Entity type:Organization
Organization Name:COLISEUM EYEWEAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:LITWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-757-1120
Mailing Address - Street 1:611 COLISEUM DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-5310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:611 COLISEUM DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-5310
Practice Address - Country:US
Practice Address - Phone:336-397-7200
Practice Address - Fax:336-757-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier