=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396049607
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYESHOPPE OF ORLANDO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2010
-----------------------------------------------------
Last Update Date | 12/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10209 E COLONIAL DR 130
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-382-7701
-----------------------------------------------------
Fax | 407-382-7702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10209 E COLONIAL DR 130
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32817-4306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-382-7701
-----------------------------------------------------
Fax | 407-382-7702
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OPTICIAN
-----------------------------------------------------
Name | MR. ROBERT HERNANDEZ UYCOCO
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 407-382-7701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number | OE1930
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------