=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477120723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVANS TELEOPTOMETRIC SERVICE FL PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2021
-----------------------------------------------------
Last Update Date | 06/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1270 SAXON BLVD STE 105
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-8418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-774-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1270 SAXON BLVD STE 105
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-8418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-774-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER OF OPEN DOCTOR PANEL
-----------------------------------------------------
Name | LAURA BASILE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-243-8708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------