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General NPI Number Information
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NPI Number | 1669765665
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Entity Type | Organization
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Legal Business Name | EYEWEAR REPUBLIC
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Dates
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Enumeration Date | 05/24/2011
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Last Update Date | 05/24/2011
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Provider Practice Location Address
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Address Line | 567 E SAMPLE RD
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City | POMPANO BEACH
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State | FL
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Zip | 33064-4425
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Country | US
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Telephone | 801-808-5397
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Fax |
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Provider Business Mailing Address
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Address Line | 160 SW 117TH TER APT 104
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City | PEMBROKE PINES
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State | FL
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Zip | 33025-3491
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Country | US
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Telephone | 801-808-5397
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DELL BENJAMIN WHITE
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Credential | O.D.
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Telephone | 801-808-5397
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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 | OPC4577
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License Number State | FL
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