1558475400 NPI number — FORT LAUDERDALE EYE INSTITUTE

Table of content: (NPI 1558475400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558475400 NPI number — FORT LAUDERDALE EYE INSTITUTE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORT LAUDERDALE EYE INSTITUTE
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:
1558475400
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/29/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 39209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33339-9209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-741-5555
Provider Business Mailing Address Fax Number:
954-572-9658

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
850 S PINE ISLAND RD
Provider Second Line Business Practice Location Address:
SUITE A100
Provider Business Practice Location Address City Name:
PLANTATION
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33324-3118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-741-5555
Provider Business Practice Location Address Fax Number:
954-572-9658
Provider Enumeration Date:
08/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SKOLNICK
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-741-5555

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , 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: 40276 . This is a "BLUE CROSS BLUE SHEILD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 250805200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008333000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".