1386821379 NPI number — FAMILY VISION INSTITUTE OF SOUTH FLORIDA INC.

Table of content: (NPI 1386821379)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386821379 NPI number — FAMILY VISION INSTITUTE OF SOUTH FLORIDA INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY VISION INSTITUTE OF SOUTH FLORIDA 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:
VISION SOURCE FORT LAUDERDALE
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:
1386821379
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
640 N FEDERAL HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33304-4686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-522-3918
Provider Business Mailing Address Fax Number:
954-522-5137

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 N FEDERAL HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33304-4686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-522-3918
Provider Business Practice Location Address Fax Number:
954-522-5137
Provider Enumeration Date:
01/22/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CORNISH
Authorized Official First Name:
BRANDON
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
954-522-3918

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC4217 , 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: 621267100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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