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General NPI Number Information
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NPI Number | 1639325434
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Entity Type | Organization
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Legal Business Name | SUPER OPTICAL EXPRESS
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Dates
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Enumeration Date | 08/12/2008
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Last Update Date | 10/26/2011
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Provider Practice Location Address
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Address Line | 6757 W NEWBERRY RD
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City | GAINESVILLE
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State | FL
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Zip | 32605-4312
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Country | US
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Telephone | 352-331-2040
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Fax | 352-331-1526
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Provider Business Mailing Address
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Address Line | 6757 W NEWBERRY RD
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City | GAINESVILLE
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State | FL
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Zip | 32605-4312
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Country | US
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Telephone | 352-331-2040
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Fax | 352-331-1526
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | DR. PAUL E FUNDERBURK
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Credential | O.D.
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Telephone | 352-331-2040
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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 | 796
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License Number State | FL
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