MEDICARE: DAVIE BLVD. VISION CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152WC0802X	Corneal and Contact Management Optometrist	OPC1180	FL
2	152WP0200X	Pediatric Optometrist	OPC1180	FL
3	156FX1800X	Optician
4	152W00000X	Optometrist	OPC1180	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144466848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIE BLVD. VISION CENTER

Provider Business Mailing Address
First Line	:	3252 DAVIE BLVD
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-2766
Country	:	US
Telephone Number	:	954-587-2020
Fax Number	:	954-587-6563

Provider Business Practice Location Address
First Line	:	3252 DAVIE BLVD
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33312-2766
Country	:	US
Telephone Number	:	954-587-2020
Fax Number	:	954-587-6563

Authorized Official
Title or Position	:	INSURANCE ADMINISTRATION
Name	:	SHARON CLIFTON
Credential	:
Telephone Number	:	850-339-5794

Provider Enumeration Date	:	12/30/2008
Last Update Date	:	12/30/2008

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Directions to “DAVIE BLVD. VISION CENTER ” Practice Location

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