=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093599896
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HELEN SULLIVAN LDO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2023
-----------------------------------------------------
Last Update Date | 08/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9890 HUTCHINSON PARK DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32225-7205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-721-4104
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1403 DUNN AVE STE 16
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-4870
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-757-5222
-----------------------------------------------------
Fax | 904-757-5011
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | DO2189
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------