1821354861 NPI number — SIGHT AND SUN EYEWORKS LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821354861 NPI number — SIGHT AND SUN EYEWORKS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SIGHT AND SUN EYEWORKS 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:
1821354861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15933 CLAYTON RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
BALLWIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63011-2172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-479-7379
Provider Business Mailing Address Fax Number:
850-497-6219

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6096 BERRYHILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32570-5062
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-200-4393
Provider Business Practice Location Address Fax Number:
850-623-4200
Provider Enumeration Date:
04/04/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SALAS
Authorized Official First Name:
EDITH
Authorized Official Middle Name:
VIVIANA
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
850-479-7379

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: 97937 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 001650400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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