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General NPI Number Information
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NPI Number | 1174912794
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Entity Type | Organization
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Legal Business Name | ST GEORGE OD LLC
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Dates
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Enumeration Date | 01/20/2015
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Last Update Date | 01/20/2015
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Provider Practice Location Address
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Address Line | 5058 GREENWICH PRESERVE CT
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City | BOYNTON BEACH
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State | FL
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Zip | 33436-5802
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Country | US
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Telephone | 954-624-5649
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Fax |
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Provider Business Mailing Address
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Address Line | 5058 GREENWICH PRESERVE CT
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City | BOYNTON BEACH
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State | FL
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Zip | 33436-5802
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Country | US
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Telephone | 954-624-5649
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. RETA GUIRGUIS
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Credential | O.D.
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Telephone | 954-624-5649
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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 | OPC4985
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License Number State | FL
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