Provider Demographics
NPI:1902339674
Name:SALT OPTICAL LLC
Entity Type:Organization
Organization Name:SALT OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN MASTER
Authorized Official - Phone:214-663-4238
Mailing Address - Street 1:4628 BRIMSTONE DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-6983
Mailing Address - Country:US
Mailing Address - Phone:972-629-9853
Mailing Address - Fax:
Practice Address - Street 1:9 JAMIE CT
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-6709
Practice Address - Country:US
Practice Address - Phone:972-629-9853
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-09
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7084676TX332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier