Healthcare Provider Details

I. General information

NPI: 1205829033
Provider Name (Legal Business Name): BUENA VISTA EYELAND INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 02/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 US HIGHWAY 1
SEBASTIAN FL
32958-3834
US

IV. Provider business mailing address

1619 US HIGHWAY 1
SEBASTIAN FL
32958-3834
US

V. Phone/Fax

Practice location:
  • Phone: 772-388-9330
  • Fax: 772-388-3036
Mailing address:
  • Phone: 772-388-9330
  • Fax: 772-388-3036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC003794
License Number StateFL

VIII. Authorized Official

Name: DR. CARLO DANIEL FODOR
Title or Position: PRESIDENT
Credential: OD
Phone: 772-388-9330