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General NPI Number Information
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NPI Number | 1518135326
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Entity Type | Organization
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Legal Business Name | VISION SOURCE OF EAST BROWARD LLC
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Dates
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Enumeration Date | 02/14/2008
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Last Update Date | 06/28/2018
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Provider Practice Location Address
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Address Line | 2419 E COMMERCIAL BLVD STE 100
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308
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Country | US
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Telephone | 954-771-9120
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Fax | 954-771-4883
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Provider Business Mailing Address
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Address Line | 2419 E COMMERCIAL BLVD STE 100
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-4042
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Country | US
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Telephone | 954-771-9120
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Fax | 954-771-4883
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Authorized Official
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Title or Position | DOCTOR
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Name | JON STEPHEN JACOBS
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Credential |
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Telephone | 954-771-9120
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC951
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License Number State | FL
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