Provider Demographics
NPI:1205103215
Name:20-10 OPTICAL, LLC
Entity type:Organization
Organization Name:20-10 OPTICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MGRM
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:MUNGENAST
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:941-833-9044
Mailing Address - Street 1:121 E MARION AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-3635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 E MARION AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-3635
Practice Address - Country:US
Practice Address - Phone:941-833-9044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-18
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE 1978332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier