Healthcare Provider Details

I. General information

NPI: 1316539927
Provider Name (Legal Business Name): EYE DESIGN EYEWEAR., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W GRANADA BLVD STE 1
ORMOND BEACH FL
32174-5941
US

IV. Provider business mailing address

900 W GRANADA BLVD STE 1
ORMOND BEACH FL
32174-5941
US

V. Phone/Fax

Practice location:
  • Phone: 386-675-6599
  • Fax: 386-256-2007
Mailing address:
  • Phone: 386-675-6599
  • Fax: 386-256-2007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JODI BUTLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 386-675-6599