Healthcare Provider Details

I. General information

NPI: 1023295763
Provider Name (Legal Business Name): PELICAN PLAZA OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 03/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8390 S TAMIAMI TRL
SARASOTA FL
34238-2934
US

IV. Provider business mailing address

8390 S TAMIAMI TRL
SARASOTA FL
34238-2934
US

V. Phone/Fax

Practice location:
  • Phone: 941-966-1559
  • Fax: 941-966-1559
Mailing address:
  • Phone: 941-966-1559
  • Fax: 941-966-1559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3259
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number3259
License Number StateFL

VIII. Authorized Official

Name: MR. JOHN GRONDAHL
Title or Position: OPTICIAN/OWNER
Credential: D.O.
Phone: 941-966-1559