=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619393915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMELIA ISLAND OPTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2014
-----------------------------------------------------
Last Update Date | 12/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1523 SADLER RD
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-4467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-5955
-----------------------------------------------------
Fax | 904-261-5956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1480 SADLER RD
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-4426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-5955
-----------------------------------------------------
Fax | 904-261-5956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ROCKATONIA BRADLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-277-2779
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332H00000X
-----------------------------------------------------
Taxonomy Name | Eyewear Supplier
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC1462
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------