1043478704 NPI number — FAMILY VISION ASSOCIATES, P.A.

Table of content: (NPI 1043478704)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043478704 NPI number — FAMILY VISION ASSOCIATES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY VISION ASSOCIATES, P.A.
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:
6
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:
1043478704
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11380 PROSPERITY FARMS RD
Provider Second Line Business Mailing Address:
SUITE 119
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-3464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-627-1114
Provider Business Mailing Address Fax Number:
561-627-2304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11380 PROSPERITY FARMS RD
Provider Second Line Business Practice Location Address:
SUITE 119
Provider Business Practice Location Address City Name:
PALM BEACH GARDENS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-3464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-627-1114
Provider Business Practice Location Address Fax Number:
561-627-2304
Provider Enumeration Date:
05/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HAUGEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-627-1114

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC002181 , 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: 078980100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 19389 . This is a "BLUE CROSS & BLUE SHIELD OF FLORIDA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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