=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063502458
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PGA EYE ASSOCIATES,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 10/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6271 PGA BLVD SUITE 202
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33418-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-799-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6271 PGA BLVD SUITE 202
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33418-4034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-799-3930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. VIVIENNE LAURA ROSENBUSCH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-799-3930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------