1184750267 NPI number — FOR EYES OPTICAL OF PA

Table of content: (NPI 1184750267)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184750267 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:
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:
1184750267
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2020
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:
88 NEEDHAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-928-0770
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2007

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:  5610 , 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)





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