Provider Demographics
NPI:1942395181
Name:DIETZ MCLEAN OPTICAL
Entity type:Organization
Organization Name:DIETZ MCLEAN OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-490-1407
Mailing Address - Street 1:300 W BITTERS RD
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-1691
Mailing Address - Country:US
Mailing Address - Phone:210-490-1407
Mailing Address - Fax:
Practice Address - Street 1:300 W BITTERS RD
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-1691
Practice Address - Country:US
Practice Address - Phone:210-490-1407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2011-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX086160101Medicaid
TX086160101Medicaid