Basic Information
| Provider Information | |||||||||
| NPI: | 1063593614 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STEIN OPTICAL INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STEIN OPTICAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846309 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2105246663 | ||||||||
| FaxNumber: | 2105246587 | ||||||||
| Practice Location | |||||||||
| Address1: | 622 S CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | WATERTOWN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9202629200 | ||||||||
| FaxNumber: | 9202628915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2006 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | NEWCOM | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2105246700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 38717300 | 05 | WI | MEDICAID |