Healthcare Provider Details

I. General information

NPI: 1205226834
Provider Name (Legal Business Name): LTA VISION CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7265 NW 173RD DR APT 712
HIALEAH FL
33015-8405
US

IV. Provider business mailing address

7265 NW 173RD DR APT 712
HIALEAH FL
33015-8405
US

V. Phone/Fax

Practice location:
  • Phone: 786-280-5923
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT 4793
License Number StateFL

VIII. Authorized Official

Name: LINA TATIANA ARANGO
Title or Position: PRESIDENT
Credential: O.D.
Phone: 786-280-5923