Healthcare Provider Details

I. General information

NPI: 1013799295
Provider Name (Legal Business Name): JENNIFER EADY LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 S FLORIDA AVE
LAKELAND FL
33803-4860
US

IV. Provider business mailing address

3501 S FLORIDA AVE
LAKELAND FL
33803-4860
US

V. Phone/Fax

Practice location:
  • Phone: 863-644-9461
  • Fax:
Mailing address:
  • Phone: 863-644-9461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberDO4568
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: