Healthcare Provider Details

I. General information

NPI: 1194256545
Provider Name (Legal Business Name): FIRST IMAGE OPTICAL LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5743 WILLIAMSBURG LN
WILDWOOD FL
34785-8129
US

IV. Provider business mailing address

17562 US HIGHWAY 441
MOUNT DORA FL
32757-6711
US

V. Phone/Fax

Practice location:
  • Phone: 352-744-7002
  • Fax:
Mailing address:
  • Phone: 352-735-2020
  • Fax: 352-735-5187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GEORGE L NEAL
Title or Position: PRESIDENT
Credential:
Phone: 469-214-0144