1417597816 NPI number — MYEYEDR OPTOMETRY OF FLORIDA, LLC

Table of content: (NPI 1417597816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417597816 NPI number — MYEYEDR OPTOMETRY OF FLORIDA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYEYEDR OPTOMETRY OF FLORIDA, LLC
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:
1417597816
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8614 WESTWOOD CENTER DR FL 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
571-223-6780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1128 BICHARA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LADY LAKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32159-7716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-750-2414
Provider Business Practice Location Address Fax Number:
352-259-4286
Provider Enumeration Date:
01/14/2020

Additional Information

Authorized Official

Authorized Official Last Name:
DOWNES
Authorized Official First Name:
SUE
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
703-847-8899

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)

  • Identifier: 014674145 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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