=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851507552
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | YOUNG EYE ASSOCIATES OD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1869 NW 20TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33142-7431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-494-9321
-----------------------------------------------------
Fax | 305-403-6967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10676 NW 19TH ST
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33172-2542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-494-9321
-----------------------------------------------------
Fax | 305-403-6967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST SOLE PROPRIETOR
-----------------------------------------------------
Name | GUY YOUNG
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 305-494-9321
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC3765
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------