1265774178 NPI number — EYE EXPRESS, INC

Table of content: (NPI 1265774178)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265774178 NPI number — EYE EXPRESS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE EXPRESS, 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:
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:
1265774178
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 1ST ST N
Provider Second Line Business Mailing Address:
STE. 100
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33881-4537
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-299-8908
Provider Business Mailing Address Fax Number:
863-299-1061

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3140 CITRUS TOWER BLVD
Provider Second Line Business Practice Location Address:
BLDG 11
Provider Business Practice Location Address City Name:
CLERMONT
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34711-6888
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-875-6568
Provider Business Practice Location Address Fax Number:
863-299-1061
Provider Enumeration Date:
03/19/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SALOMON
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
863-875-6568

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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