Provider Demographics
NPI:1902979792
Name:CERTIFIED CC OPTICIANS
Entity Type:Organization
Organization Name:CERTIFIED CC OPTICIANS
Other - Org Name:PUBLIC WHOLESALE OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-367-9401
Mailing Address - Street 1:1173 E 42ND STREET
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762
Mailing Address - Country:US
Mailing Address - Phone:432-367-9401
Mailing Address - Fax:432-362-2327
Practice Address - Street 1:1173 E 42ND STREET
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79762
Practice Address - Country:US
Practice Address - Phone:432-367-9401
Practice Address - Fax:432-362-2327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXABO3472156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty