Provider Demographics
NPI:1932378056
Name:SHANNON RIVER ENTERPRISES,INC.
Entity Type:Organization
Organization Name:SHANNON RIVER ENTERPRISES,INC.
Other - Org Name:THE OPTICAL SHOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:HOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:352-331-1933
Mailing Address - Street 1:6830 NW 11TH PL
Mailing Address - Street 2:SUITE C
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4254
Mailing Address - Country:US
Mailing Address - Phone:352-331-1933
Mailing Address - Fax:352-331-7428
Practice Address - Street 1:6830 NW 11TH PL
Practice Address - Street 2:SUITE C
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4254
Practice Address - Country:US
Practice Address - Phone:352-331-1933
Practice Address - Fax:352-331-7428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-22
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO431332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0920240001Medicare PIN
FL0920240001Medicare NSC