=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194110403
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACQUELINE E. ZERMENO O.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2015
-----------------------------------------------------
Last Update Date | 04/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3550 S WASHINGTON AVE
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32780-8627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-268-9239
-----------------------------------------------------
Fax | 321-383-0788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1621 HOLLAND ST
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32935-2826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-412-1983
-----------------------------------------------------
Fax | 321-383-0788
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. JACQUELINE ELIZA ZERMENO
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 321-412-1983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 4604
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------