Provider Demographics
NPI:1780759472
Name:TRENDSETTERS OPTICAL LLC
Entity type:Organization
Organization Name:TRENDSETTERS OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-577-1076
Mailing Address - Street 1:324 N MASSEY BLVD
Mailing Address - Street 2:
Mailing Address - City:NIXA
Mailing Address - State:MO
Mailing Address - Zip Code:65714-8307
Mailing Address - Country:US
Mailing Address - Phone:417-725-0303
Mailing Address - Fax:
Practice Address - Street 1:324 N MASSEY BLVD
Practice Address - Street 2:
Practice Address - City:NIXA
Practice Address - State:MO
Practice Address - Zip Code:65714-8307
Practice Address - Country:US
Practice Address - Phone:417-725-0303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310813951Medicaid
MO329359111Medicaid