Basic Information
| Provider Information | |||||||||
| NPI: | 1699951756 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAK CREEK OPTICAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RICHARD D. GROSSNICKLE, M.D. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2615 NE LOOP 286 | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754603444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037850443 | ||||||||
| FaxNumber: | 9037852947 | ||||||||
| Practice Location | |||||||||
| Address1: | 2615 NE LOOP 286 | ||||||||
| Address2: | |||||||||
| City: | PARIS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 754603444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037850443 | ||||||||
| FaxNumber: | 9037852947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2008 | ||||||||
| LastUpdateDate: | 03/10/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GROSSNICKLE | ||||||||
| AuthorizedOfficialFirstName: | A | ||||||||
| AuthorizedOfficialMiddleName: | LISA | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9037850443 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | E6388 | TX | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 1100976-02 | 05 | TX | MEDICAID |