Healthcare Provider Details

I. General information

NPI: 1689774812
Provider Name (Legal Business Name): OPTICAL FACTORY AND SHOWROOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E BAY DR SUITE G
LARGO FL
33770-2532
US

IV. Provider business mailing address

800 E BAY DR SUITE G
LARGO FL
33770-2532
US

V. Phone/Fax

Practice location:
  • Phone: 727-585-8521
  • Fax: 727-584-1973
Mailing address:
  • Phone: 727-585-8521
  • Fax: 727-584-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number3570
License Number StateFL

VIII. Authorized Official

Name: MRS. KARA S COLECCHIA
Title or Position: OPTICIAN, OWNER
Credential: LDO
Phone: 727-585-8521