Healthcare Provider Details

I. General information

NPI: 1447696018
Provider Name (Legal Business Name): VITRECTOMY RECOVERY EQUIPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 W WINDY WILLOW DR
ST AUGUSTINE FL
32092-5094
US

IV. Provider business mailing address

1509 W WINDY WILLOW DR
ST AUGUSTINE FL
32092-5094
US

V. Phone/Fax

Practice location:
  • Phone: 904-230-5400
  • Fax:
Mailing address:
  • Phone: 904-230-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateFL

VIII. Authorized Official

Name: MR. CARL EUGENE BOX
Title or Position: VICE PRESIDENT
Credential:
Phone: 904-230-5400