Healthcare Provider Details

I. General information

NPI: 1487031233
Provider Name (Legal Business Name): OPTIKK 30A, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2015
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 W COUNTY HIGHWAY 30A M1-119
SANTA ROSA BEACH FL
32459-0187
US

IV. Provider business mailing address

2050 HWY 30A M 1-119
SANTA ROSA BEACH FL
32459
US

V. Phone/Fax

Practice location:
  • Phone: 850-608-3135
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC 3910
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOPC3910
License Number StateFL

VIII. Authorized Official

Name: DR. KORRIE L LALIM
Title or Position: CEO
Credential: O.D.
Phone: 850-608-3135