1255523411 NPI number — FOR EYES OPTICAL OF PA

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 1255523411 NPI number — FOR EYES OPTICAL OF PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOR EYES OPTICAL OF PA
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:
FOR EYES
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:
1255523411
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
07/10/2013
NPI Reactivation Date:
08/02/2013

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3601 SW 160TH AVE STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33027-6312
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-557-9004
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 WAYSIDE RD
Provider Second Line Business Practice Location Address:
UNIT 2G
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
01803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-273-0198
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/13/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRIFFIN
Authorized Official First Name:
KIM
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
305-557-9004

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  4927 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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