Healthcare Provider Details

I. General information

NPI: 1629596200
Provider Name (Legal Business Name): OPTIX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2017
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9001 TABORFIELD AVE STE 101
ORLANDO FL
32836-8905
US

IV. Provider business mailing address

9001 TABORFIELD AVE STE 101
ORLANDO FL
32836-8905
US

V. Phone/Fax

Practice location:
  • Phone: 407-217-7375
  • Fax:
Mailing address:
  • Phone: 407-217-7375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOPC5035
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC5035
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5035
License Number StateFL

VIII. Authorized Official

Name: DR. PAMELA JISELLE BLADE
Title or Position: OPTOMETRIST/OWNER
Credential: OD
Phone: 407-217-7375