Healthcare Provider Details

I. General information

NPI: 1205654290
Provider Name (Legal Business Name): EAGLEVISION OPTICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13256 SW 8TH ST
MIAMI FL
33184-1178
US

IV. Provider business mailing address

13256 SW 8TH ST
MIAMI FL
33184-1178
US

V. Phone/Fax

Practice location:
  • Phone: 305-870-7555
  • Fax:
Mailing address:
  • Phone: 305-870-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: ESLER GONZALEZ
Title or Position: OPTOMETRIST
Credential: OD
Phone: 786-332-9636