1720232648 NPI number — FOUR H OPTICAL

Table of content: (NPI 1720232648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720232648 NPI number — FOUR H OPTICAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR H OPTICAL
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:
1720232648
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4605 NW 6TH ST
Provider Second Line Business Mailing Address:
SUITE 2C
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32609-4197
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-377-0532
Provider Business Mailing Address Fax Number:
352-338-8001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2441 NW 43RD ST
Provider Second Line Business Practice Location Address:
SUITE 2C
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32606-7469
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-377-0532
Provider Business Practice Location Address Fax Number:
352-338-8001
Provider Enumeration Date:
11/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HOUGH
Authorized Official First Name:
MAUDE
Authorized Official Middle Name:
LUCILLE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
352-377-0532

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  5019 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 156FX1800X , with the licence number: 3940 , 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: 630303001 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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