Healthcare Provider Details

I. General information

NPI: 1225153455
Provider Name (Legal Business Name): FOUR H OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4605 NW 6TH ST SUITE 2C
GAINESVILLE FL
32609-4197
US

IV. Provider business mailing address

4605 NW 6TH ST SUITE 2C
GAINESVILLE FL
32609-4197
US

V. Phone/Fax

Practice location:
  • Phone: 352-377-0532
  • Fax: 352-338-8001
Mailing address:
  • Phone: 352-377-0532
  • Fax: 352-338-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number5019
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. MAUDE LUCILLE HOUGH
Title or Position: OWNER
Credential:
Phone: 352-377-0532