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General NPI Number Information
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NPI Number | 1023295763
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Entity Type | Organization
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Legal Business Name | PELICAN PLAZA OPTICAL
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Dates
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Enumeration Date | 01/24/2008
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Last Update Date | 03/24/2008
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Provider Practice Location Address
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Address Line | 8390 S TAMIAMI TRL
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City | SARASOTA
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State | FL
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Zip | 34238-2934
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Country | US
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Telephone | 941-966-1559
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Fax | 941-966-1559
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Provider Business Mailing Address
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Address Line | 8390 S TAMIAMI TRL
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City | SARASOTA
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State | FL
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Zip | 34238-2934
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Country | US
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Telephone | 941-966-1559
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Fax | 941-966-1559
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Authorized Official
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Title or Position | OPTICIAN/OWNER
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Name | MR. JOHN GRONDAHL
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Credential | D.O.
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Telephone | 941-966-1559
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number | 3259
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 3259
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License Number State | FL
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