Healthcare Provider Details

I. General information

NPI: 1235317983
Provider Name (Legal Business Name): OPTIQUE UNIQUE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 N MIRAMAR AVE
INDIALANTIC FL
32903-3054
US

IV. Provider business mailing address

880 N MIRAMAR AVE
INDIALANTIC FL
32903-3054
US

V. Phone/Fax

Practice location:
  • Phone: 321-729-4340
  • Fax:
Mailing address:
  • Phone: 321-729-4340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number2197
License Number StateFL

VIII. Authorized Official

Name: MR. KEITH BARRY SMITH
Title or Position: OPTICIAN
Credential: OPTICIAN
Phone: 321-729-4340