Healthcare Provider Details

I. General information

NPI: 1740531417
Provider Name (Legal Business Name): CEPERO EYECARE CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2012
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 CORAL WAY
MIAMI FL
33145-2728
US

IV. Provider business mailing address

1705 CORAL WAY
MIAMI FL
33145-2728
US

V. Phone/Fax

Practice location:
  • Phone: 305-858-4057
  • Fax: 305-858-4053
Mailing address:
  • Phone: 305-858-4057
  • Fax: 305-858-4053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4698
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberDO3239
License Number StateFL

VIII. Authorized Official

Name: DR. ERNESTO CEPERO
Title or Position: PRESIDENT
Credential: O.D.
Phone: 305-858-4057