1992839443 NPI number — OSCEOLA OPTIQUE

Table of content: (NPI 1992839443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992839443 NPI number — OSCEOLA OPTIQUE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OSCEOLA OPTIQUE
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:
1992839443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3201 NE SKYLINE DR
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
JENSEN BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34957-3912
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-334-4264
Provider Business Mailing Address Fax Number:
772-334-4265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3201 NE SKYLINE DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
JENSEN BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34957-3912
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-334-4264
Provider Business Practice Location Address Fax Number:
772-334-4265
Provider Enumeration Date:
03/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHANG
Authorized Official First Name:
JEWELL
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
772-334-4264

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  OPC2950 , 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: 20621 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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