1831543362 NPI number — OKALOOSA OPHTHALMOLOGY PEDIATRIC & ADULT EYE CARE

Table of content: (NPI 1831543362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831543362 NPI number — OKALOOSA OPHTHALMOLOGY PEDIATRIC & ADULT EYE CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKALOOSA OPHTHALMOLOGY PEDIATRIC & ADULT EYE CARE
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:
1831543362
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1299 INDUSTRIAL DR
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
CRESTVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32539-8946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-683-3937
Provider Business Mailing Address Fax Number:
850-683-0227

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1299 INDUSTRIAL DR
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CRESTVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32539-8946
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-683-3937
Provider Business Practice Location Address Fax Number:
850-683-0227
Provider Enumeration Date:
04/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KRUGER
Authorized Official First Name:
TIFFANY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-826-2903

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MYHJK . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 017548800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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