Healthcare Provider Details

I. General information

NPI: 1982621884
Provider Name (Legal Business Name): ECSA OPTICAL COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 10/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 US HIGHWAY 1 S
ST AUGUSTINE FL
32084-4211
US

IV. Provider business mailing address

1400 US HIGHWAY 1 S
ST AUGUSTINE FL
32084-4211
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-2286
  • Fax: 904-829-5447
Mailing address:
  • Phone: 904-829-2286
  • Fax: 904-829-5447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberME68633
License Number StateFL

VIII. Authorized Official

Name: PAUL W HUND III
Title or Position: MANAGER
Credential: MD
Phone: 904-829-2286