1215077557 NPI number — EYESUPPLY

Table of content: (NPI 1215077557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215077557 NPI number — EYESUPPLY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYESUPPLY
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 EYEGLASS SUPERSTORE
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:
1215077557
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
785 N WICKHAM RD
Provider Second Line Business Mailing Address:
STE. 106
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32935-8857
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-259-3935
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
785 N WICKHAM RD
Provider Second Line Business Practice Location Address:
STE. 106
Provider Business Practice Location Address City Name:
MELBOURNE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32935-8857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-259-3935
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
UCCI
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
Authorized Official Title or Position:
GENERAL MANAGER
Authorized Official Telephone Number:
321-259-3935

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC2732 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 156FC0801X , with the licence number: DO5119 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 156FC0801X , with the licence number: DO3652 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 156FX1800X , with the licence number: DO5119 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 156FX1800X , with the licence number: DO3652 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 332H00000X , with the licence number: OE1487 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: FL2732 . This is a "EYEMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 29268 . This is a "SPECTRA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: FL5119 . This is a "EYEMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".