Basic Information
| Provider Information | |||||||||
| NPI: | 1417982935 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAM'S CLUB OPTICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 702 SW 8TH ST | ||||||||
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| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727166209 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3410 55TH ST NW | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559010123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5072818355 | ||||||||
| FaxNumber: | 4792778176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAYNES | ||||||||
| AuthorizedOfficialFirstName: | LAURIE | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 4792048495 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.