1023102902 NPI number — 2020 EYECARE NETWORK, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023102902 NPI number — 2020 EYECARE NETWORK, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
2020 EYECARE NETWORK, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
2020 EYECARE NETWORK
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023102902
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 W CYPRESS CREEK RD
Provider Second Line Business Mailing Address:
SUITE 4
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33309-1715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-979-2407
Provider Business Mailing Address Fax Number:
954-979-8988

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 W CYPRESS CREEK RD
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-979-2407
Provider Business Practice Location Address Fax Number:
954-979-2407
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COPPOLA
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-979-2407

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC 1910 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 104112800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 108023500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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