=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679765911
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE CENTER OF SOUTH FLORIDA, CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2007
-----------------------------------------------------
Last Update Date | 03/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1951 NW 150TH AVE SUITE NUMBER B102
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33028-2875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-430-7338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1951 NW 150TH AVE SUITE NUMBER B102
-----------------------------------------------------
City | PEMBROKE PINES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33028-2875
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-430-7338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. ILIANA MARIA TORAL
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 954-430-7338
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 3615
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------