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General NPI Number Information
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NPI Number | 1184904260
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Entity Type | Organization
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Legal Business Name | 411 EYES, LLC.
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Dates
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Enumeration Date | 08/22/2011
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Last Update Date | 11/03/2011
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Provider Practice Location Address
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Address Line | 1270 SAXON BLVD SUITE 105
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City | ORANGE CITY
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State | FL
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Zip | 32763-8418
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Country | US
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Telephone | 386-774-5000
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Fax | 386-774-0444
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Provider Business Mailing Address
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Address Line | 1270 SAXON BLVD SUITE 105
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City | ORANGE CITY
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State | FL
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Zip | 32763-8418
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Country | US
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Telephone | 386-774-5000
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Fax | 386-774-0444
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | MR. EDWARD UCCI
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Credential | ABOC NCLE
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Telephone | 407-767-5600
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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 | 2732
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License Number State | FL
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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 | DO 5119
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | OE 2002
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License Number State | FL
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