{
"Npi": {
"NPI": "1215077557",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "EYESUPPLY",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": "6",
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "785 N WICKHAM RD",
"SecondLineMailingAddress": "STE. 106",
"MailingAddressCityName": "MELBOURNE",
"MailingAddressStateName": "FL",
"MailingAddressPostalCode": "32935-8857",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "321-259-3935",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "785 N WICKHAM RD",
"SecondLinePracticeLocationAddress": "STE. 106",
"PracticeLocationAddressCityName": "MELBOURNE",
"PracticeLocationAddressStateName": "FL",
"PracticeLocationAddressPostalCode": "32935-8857",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "321-259-3935",
"PracticeLocationAddressFaxNumber": null,
"EnumerationDate": "02/07/2007",
"LastUpdateDate": "09/11/2025",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "UCCI",
"AuthorizedOfficialFirstName": "EDWARD",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "GENERAL MANAGER",
"AuthorizedOfficialNamePrefix": "MR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "ABOC NCLE",
"AuthorizedOfficialTelephoneNumber": "321-259-3935",
"Taxonomies": {
"Taxonomy": [
{
"TaxonomyCode": "152W00000X",
"TaxonomyName": "Optometrist",
"LicenseNumber": "OPC2732",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "156FC0801X",
"TaxonomyName": "Contact Lens Fitter",
"LicenseNumber": "DO5119",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "156FC0801X",
"TaxonomyName": "Contact Lens Fitter",
"LicenseNumber": "DO3652",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "156FX1800X",
"TaxonomyName": "Optician",
"LicenseNumber": "DO5119",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "156FX1800X",
"TaxonomyName": "Optician",
"LicenseNumber": "DO3652",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "N"
},
{
"TaxonomyCode": "332H00000X",
"TaxonomyName": "Eyewear Supplier",
"LicenseNumber": "OE1487",
"LicenseNumberStateCode": "FL",
"PrimaryTaxonomySwitch": "Y"
}
]
},
"HealthcareProviderTaxonomyGroups": {
"HealthcareProviderTaxonomyGroup": [
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
},
{
"HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
"HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
}
]
}
}
}