Healthcare Provider Details

I. General information

NPI: 1265883797
Provider Name (Legal Business Name): PREVMED OPTOMETRY GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 08/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2011 FLAGLER AVE
KEY WEST FL
33040-3732
US

IV. Provider business mailing address

1499 WINDHORST WAY STE 120
GREENWOOD IN
46143-8800
US

V. Phone/Fax

Practice location:
  • Phone: 317-522-2054
  • Fax: 855-671-4102
Mailing address:
  • Phone: 317-522-2054
  • Fax: 855-671-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: CLAUDIA JACKSON
Title or Position: VP OF FINANACE
Credential:
Phone: 317-522-2054