Healthcare Provider Details

I. General information

NPI: 1134589732
Provider Name (Legal Business Name): DRIFTWOOD VISION CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2016
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S PATRICK DR SUITE 104
PATRICK AIR FORCE BASE FL
32925-3623
US

IV. Provider business mailing address

1221 S. PATRICK DRIVE SUITE 104
PATRICK AIR FORCE BASE FL
32925
US

V. Phone/Fax

Practice location:
  • Phone: 321-783-8820
  • Fax:
Mailing address:
  • Phone: 321-783-8820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3269
License Number StateFL

VIII. Authorized Official

Name: DR. BRETT C REYNOLDS
Title or Position: PRESIDENT
Credential: OD
Phone: 321-783-8820