1174517940 NPI number — EYE EXPRESS, INC

Table of content: (NPI 1174517940)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174517940 NPI number — EYE EXPRESS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE EXPRESS, 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:
Provider Other Organization Name Type Code:
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:
1174517940
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 1ST ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33881-4537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-875-6568
Provider Business Mailing Address Fax Number:
863-299-1061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1251 LAKELAND HILLS BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33805-4673
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-875-6568
Provider Business Practice Location Address Fax Number:
863-299-1031
Provider Enumeration Date:
09/07/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
863-299-8908

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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