=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730458456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER EYE GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2011
-----------------------------------------------------
Last Update Date | 04/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13852 SW 88TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-1304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-804-0645
-----------------------------------------------------
Fax | 305-380-7106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9549 NW 41ST ST
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33178-2371
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-804-0645
-----------------------------------------------------
Fax | 305-380-7106
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/OFFICER
-----------------------------------------------------
Name | DR. JESUS CUEVAS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 305-385-6885
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC 4122
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------