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General NPI Number Information
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NPI Number | 1023807716
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Entity Type | Organization
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Legal Business Name | SPACECOASTPOP LLC
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Dates
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Enumeration Date | 05/01/2025
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Last Update Date | 05/01/2025
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Provider Practice Location Address
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Address Line | 601 E STRAWBRIDGE AVE
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City | MELBOURNE
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State | FL
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Zip | 32901-4733
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Country | US
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Telephone | 321-301-0411
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Fax |
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Provider Business Mailing Address
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Address Line | 331 MELBOURNE AVE
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City | INDIALANTIC
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State | FL
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Zip | 32903-4315
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Country | US
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Telephone | 321-243-5255
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Fax | 321-243-5255
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Authorized Official
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Title or Position | PRESIDENT
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Name | ERICK ROSS
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Credential | LICENSED OPTICIAN
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Telephone | 321-243-5255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FC0801X
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Taxonomy Name | Contact Lens Fitter
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 156FX1800X
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Taxonomy Name | Optician
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License Number |
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License Number State |
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