=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154461721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOR EYES OPTICAL OF COCONUT GROVE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 10/30/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16201 NW 57TH AVE
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-6709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-628-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 W 74TH PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014-5058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. PHILIP WOLMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-557-9004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | DO 1565
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------