Healthcare Provider Details

I. General information

NPI: 1972969749
Provider Name (Legal Business Name): PCP VISION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6517 TAFT ST
HOLLYWOOD FL
33024-4062
US

IV. Provider business mailing address

6517 TAFT ST
HOLLYWOOD FL
33024-4062
US

V. Phone/Fax

Practice location:
  • Phone: 954-983-9191
  • Fax: 954-983-1152
Mailing address:
  • Phone: 954-983-9191
  • Fax: 954-983-1152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MOISES ISSA
Title or Position: PRESIDENT
Credential: MD
Phone: 954-983-9191