Healthcare Provider Details

I. General information

NPI: 1619393915
Provider Name (Legal Business Name): AMELIA ISLAND OPTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1523 SADLER RD
FERNANDINA BEACH FL
32034-4467
US

IV. Provider business mailing address

1480 SADLER RD
FERNANDINA BEACH FL
32034-4426
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-5955
  • Fax: 904-261-5956
Mailing address:
  • Phone: 904-261-5955
  • Fax: 904-261-5956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC1462
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: ROCKATONIA BRADLEY
Title or Position: OWNER
Credential:
Phone: 904-277-2779