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General NPI Number Information
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NPI Number | 1154867554
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Entity Type | Organization
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Legal Business Name | CABANA EYES OPTICAL
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Dates
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Enumeration Date | 01/10/2017
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Last Update Date | 10/23/2019
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Provider Practice Location Address
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Address Line | 4100 S FERDON BLVD SUITE B5
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City | CRESTVIEW
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State | FL
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Zip | 32536-5252
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Country | US
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Telephone | 850-758-0474
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Fax | 850-826-0057
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Provider Business Mailing Address
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Address Line | 4100 S FERDON BLVD SUITE B5
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City | CRESTVIEW
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State | FL
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Zip | 32536-5252
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Country | US
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Telephone | 850-306-2580
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Fax | 850-423-0142
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Authorized Official
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Title or Position | OWNER/ VISUAL RESOURCE DIRECTOR
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Name | MR. EDWARD MITCHELL JR.
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Credential | LDO
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Telephone | 850-758-0474
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number |
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License Number State |
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