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General NPI Number Information
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NPI Number | 1780845222
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Entity Type | Organization
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Legal Business Name | PEMBROKE LAKES OPTICAL INC
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Dates
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Enumeration Date | 06/18/2008
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 1673 N HIATUS RD
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City | PEMBROKE PINES
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State | FL
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Zip | 33026-2129
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Country | US
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Telephone | 954-442-6703
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Fax | 954-442-6769
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Provider Business Mailing Address
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Address Line | 1673 N HIATUS RD
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City | PEMBROKE PINES
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State | FL
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Zip | 33026-2129
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Country | US
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Telephone | 954-442-6703
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Fax | 954-442-6769
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PETER L GOMEZ
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Credential | O.D.
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Telephone | 954-442-6703
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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 | OPC3345
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License Number State | FL
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