1528302510 NPI number — OPTOMETRY HOLDINGS, LLC

Table of content: (NPI 1528302510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528302510 NPI number — OPTOMETRY HOLDINGS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTOMETRY HOLDINGS, 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:
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:
1528302510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13506 SUMMERPORT VILLAGE PKWY
Provider Second Line Business Mailing Address:
#254
Provider Business Mailing Address City Name:
WINDERMERE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34786-7366
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-288-3032
Provider Business Mailing Address Fax Number:
954-491-6697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5200 N FEDERAL HWY
Provider Second Line Business Practice Location Address:
STUITE 4
Provider Business Practice Location Address City Name:
FT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33308-3253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-491-6663
Provider Business Practice Location Address Fax Number:
954-491-6667
Provider Enumeration Date:
11/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
HENRY
Authorized Official First Name:
NOEL
Authorized Official Middle Name:
ANDREW
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
954-288-3032

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC3970 , 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: U65034 . This is a "MEDICARE PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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