=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851658264
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTICAL BY THE SEA, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2012
-----------------------------------------------------
Last Update Date | 04/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 EAST COMMERCIAL BLVD. SUITE # 103
-----------------------------------------------------
City | LAUDERDALE BY THE SEA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-4430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-491-5818
-----------------------------------------------------
Fax | 954-491-5819
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 EAST COMMERCIAL BLVD. SUITE # 103
-----------------------------------------------------
City | LAUDERDALE BY THE SEA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33308-4430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-491-5818
-----------------------------------------------------
Fax | 954-491-5819
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / OPTICIAN
-----------------------------------------------------
Name | MR. STEVEN EDONAIS JORDAN
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 954-491-5818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | DO-3073
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------