Healthcare Provider Details

I. General information

NPI: 1205018132
Provider Name (Legal Business Name): EYEGLASS WORLD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 12/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18110 W BLUEMOUND RD
BROOKFIELD WI
53045-2917
US

IV. Provider business mailing address

3801 S CONGRESS AVENUE
LAKE WORTH FL
33461
US

V. Phone/Fax

Practice location:
  • Phone: 262-797-6589
  • Fax: 262-797-6604
Mailing address:
  • Phone: 561-965-9110
  • Fax: 561-642-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. BEN COOK
Title or Position: PRESIDENT
Credential:
Phone: 561-965-9110