| Organization Name: | OLDE TYME OPTICAL |
| NPI Number: | 1659759918 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DAVID ANTONE BLISSENBACH (OWNER) |
| Mailing Address: | 100 N. 8th St E. Suite 264 E. St. Louis |
| State: | IL US |
| Postal Code: | 62201 |
| Phone Number: | 6182742020 |
| Fax Number: | |
| NPI Enumeration Date: | 05/07/2015 |
| NPI Last Update Date: | 05/07/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |