=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376977686
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BOCA FAMILY EYE CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2013
-----------------------------------------------------
Last Update Date | 08/23/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4400 N STATE ROAD 7
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33073-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-372-1301
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9858 CLINT MOORE RD 107
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | DR. JONATHAN NEBB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-479-0521
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------