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General NPI Number Information
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NPI Number | 1073087474
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Entity Type | Organization
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Legal Business Name | FOR EYES OPTICAL COMPANY OF PA
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Dates
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Enumeration Date | 01/18/2019
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Last Update Date | 01/18/2019
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Provider Practice Location Address
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Address Line | 9900 S RIDGLELAND AVE
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City | CHICAGO RIDGE
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State | IL
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Zip | 60643
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Country | US
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Telephone | 708-422-9390
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Fax |
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Provider Business Mailing Address
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Address Line | 3601 SW 160TH AVE STE 400
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City | MIRAMAR
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State | FL
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Zip | 33027-6312
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Country | US
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Telephone | 305-557-9004
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | JOSE COSTA
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Credential |
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Telephone | 954-305-9004
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number |
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License Number State |
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