Healthcare Provider Details

I. General information

NPI: 1215798301
Provider Name (Legal Business Name): DESIGNER COLLECTION OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15470 NW 77TH CT
MIAMI LAKES FL
33016-5823
US

IV. Provider business mailing address

15470 NW 77TH CT
MIAMI LAKES FL
33016-5823
US

V. Phone/Fax

Practice location:
  • Phone: 786-564-2439
  • Fax:
Mailing address:
  • Phone: 786-564-2439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code156FC0801X
TaxonomyContact Lens Fitter
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MISS MITZANIA POLANCO
Title or Position: SECRETARY/OPTICIAN
Credential: DO6785
Phone: 786-564-2439