=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164167698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRECISION OPTICAL OF FLORIDA, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2022
-----------------------------------------------------
Last Update Date | 12/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2435 US HIGHWAY 19 STE 100
-----------------------------------------------------
City | HOLIDAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34691-3942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-937-6551
-----------------------------------------------------
Fax | 727-942-7200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2435 US HIGHWAY 19 STE 100
-----------------------------------------------------
City | HOLIDAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34691-3942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-937-6551
-----------------------------------------------------
Fax | 727-942-7200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/LICENSED OPTICIAN
-----------------------------------------------------
Name | TAMMY MARIE WILHITE
-----------------------------------------------------
Credential | LDO
-----------------------------------------------------
Telephone | 727-937-6551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------