Provider Demographics
NPI:1932399003
Name:S.P. OPTICAL DISPENSING LABORATORY, INC.
Entity Type:Organization
Organization Name:S.P. OPTICAL DISPENSING LABORATORY, INC.
Other - Org Name:S.P. OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAT
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAZAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-631-0270
Mailing Address - Street 1:1998 HACIENDA DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1998 HACIENDA DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6026
Practice Address - Country:US
Practice Address - Phone:760-631-0270
Practice Address - Fax:760-631-0272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABL55683269332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0728200001Medicare NSC