Healthcare Provider Details

I. General information

NPI: 1205185469
Provider Name (Legal Business Name): DR. MEDINA'S OPTICAL, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2012
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8247 SW 124TH ST
PINECREST FL
33156-5900
US

IV. Provider business mailing address

8247 SW 124TH ST
PINECREST FL
33156-5900
US

V. Phone/Fax

Practice location:
  • Phone: 305-233-1330
  • Fax: 305-233-1362
Mailing address:
  • Phone: 305-233-1330
  • Fax: 305-233-1362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License NumberOPC 4155
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOPC 4155
License Number StateFL

VIII. Authorized Official

Name: DR. ARIEL MEDINA
Title or Position: PRESIDENT
Credential: O.D.
Phone: 305-233-1330