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General NPI Number Information
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NPI Number | 1487031233
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Entity Type | Organization
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Legal Business Name | OPTIKK 30A, PA
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Dates
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Enumeration Date | 04/30/2015
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Last Update Date | 03/15/2016
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Provider Practice Location Address
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Address Line | 2050 W COUNTY HIGHWAY 30A M1-119
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459-0187
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Country | US
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Telephone | 850-608-3135
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Fax |
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Provider Business Mailing Address
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Address Line | 2050 HWY 30A M 1-119
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City | SANTA ROSA BEACH
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State | FL
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Zip | 32459
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. KORRIE L LALIM
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Credential | O.D.
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Telephone | 850-608-3135
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | OPC3910
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC 3910
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License Number State | FL
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