=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184757296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE WIZARD OF EYES OF S FL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7107 LAKE WORTH RD
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33467-2906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-966-2212
-----------------------------------------------------
Fax | 561-966-2215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7107 LAKE WORTH RD
-----------------------------------------------------
City | LAKE WORTH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33467-2906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-966-2212
-----------------------------------------------------
Fax | 561-966-2215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MARCI ANZALONE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-966-2212
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | DO5743
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------