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General NPI Number Information
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NPI Number | 1609092337
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Entity Type | Organization
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Legal Business Name | VISTA VISION EYECARE 2, INC.
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Dates
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Enumeration Date | 04/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 9918 GULF COAST MAIN SUITE B100
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City | FT. MYERS
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State | FL
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Zip | 33913
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Country | US
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Telephone | 239-482-6745
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Fax |
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Provider Business Mailing Address
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Address Line | 13625 EAGLE RIDGE DR APT 334
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City | FORT MYERS
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State | FL
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Zip | 33912-1882
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Country | US
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Telephone | 305-804-0476
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Fax | 239-265-3218
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | DR. MIGUEL ENRIQUE DE LA TORRE
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Credential | OD
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Telephone | 305-804-0476
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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 | OPC3580
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License Number State | FL
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