Provider Demographics
NPI:1235385261
Name:THIRTEENTH STREET OPTICAL CO., INC.
Entity type:Organization
Organization Name:THIRTEENTH STREET OPTICAL CO., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:WRIGHT
Authorized Official - Last Name:BARNARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-375-6133
Mailing Address - Street 1:3720 NW 13TH ST. #12
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-5911
Mailing Address - Country:US
Mailing Address - Phone:352-375-6133
Mailing Address - Fax:352-375-5380
Practice Address - Street 1:3720 NW 13TH ST. #12
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-5911
Practice Address - Country:US
Practice Address - Phone:352-375-6133
Practice Address - Fax:352-375-5380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-11
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3830156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1081800001Medicare NSC