=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053964908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANIEL MAX & MARC ANDREA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2019
-----------------------------------------------------
Last Update Date | 02/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 113 NORTHSIDE DR E
-----------------------------------------------------
City | STATESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30458-2185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-275-2020
-----------------------------------------------------
Fax | 561-828-8367
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3801 S CONGRESS AVE
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-4140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-275-2020
-----------------------------------------------------
Fax | 561-828-8367
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING MANAGER
-----------------------------------------------------
Name | JACKIE BENNETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-612-4531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------