Provider Demographics
NPI:1912443755
Name:SALEM OPTICAL OUTLET
Entity Type:Organization
Organization Name:SALEM OPTICAL OUTLET
Other - Org Name:SALEM OPTICAL COMPANY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:TRADER
Authorized Official - Last Name:LITWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-757-1120
Mailing Address - Street 1:4310 ENTERPRISE DR
Mailing Address - Street 2:SUITE I
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3260
Mailing Address - Country:US
Mailing Address - Phone:336-757-1120
Mailing Address - Fax:
Practice Address - Street 1:4310 ENTERPRISE DR
Practice Address - Street 2:SUITE I
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3260
Practice Address - Country:US
Practice Address - Phone:336-757-1120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-18
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier