Healthcare Provider Details

I. General information

NPI: 1245561893
Provider Name (Legal Business Name): VEINTE 20 VISION CENTER & OPTICAL, P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2010
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DIVINE DR SUITE 1
DAVENPORT FL
33897-9571
US

IV. Provider business mailing address

101 DIVINE DR SUITE 1
DAVENPORT FL
33897-9571
US

V. Phone/Fax

Practice location:
  • Phone: 352-243-2724
  • Fax: 863-353-6842
Mailing address:
  • Phone: 352-243-2724
  • Fax: 863-353-6842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number004008
License Number StateFL

VIII. Authorized Official

Name: DR. GUSTAVO A CASTILLO
Title or Position: OWNER
Credential: O.D.
Phone: 352-243-2724