Healthcare Provider Details

I. General information

NPI: 1841478484
Provider Name (Legal Business Name): UMATILLA OPTICAL & HEARING AID CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 HATFIELD DR
UMATILLA FL
32784-8986
US

IV. Provider business mailing address

570 HATFIELD DR
UMATILLA FL
32784-8986
US

V. Phone/Fax

Practice location:
  • Phone: 352-669-6888
  • Fax: 352-669-1015
Mailing address:
  • Phone: 352-669-6888
  • Fax: 352-669-1015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License NumberAS2700
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberDO3146
License Number StateFL

VIII. Authorized Official

Name: MRS. KATHLEEN BASTONE
Title or Position: OWNER
Credential: LDO
Phone: 352-669-6888