1861797482 NPI number — BIRD ROAD OPTICAL, INC.

Table of content: (NPI 1861797482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861797482 NPI number — BIRD ROAD OPTICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIRD ROAD OPTICAL, INC.
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:
DE VISTA OPTICAL
Provider Other Organization Name Type Code:
3
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:
1861797482
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8485 SW 40TH ST
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33155-3244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-223-6142
Provider Business Mailing Address Fax Number:
305-552-0824

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8485 SW 40TH ST
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33155-3244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-223-6142
Provider Business Practice Location Address Fax Number:
305-552-0824
Provider Enumeration Date:
01/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
REYES
Authorized Official First Name:
DORA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
305-223-6142

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332H00000X , with the licence number: OE879 , 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: 003415100 . 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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