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General NPI Number Information
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NPI Number | 1891787446
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Entity Type | Organization
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Legal Business Name | MELBOURNE UNITED LASER VISION ASSOCIATION LLC
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Dates
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Enumeration Date | 08/19/2005
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Last Update Date | 10/21/2013
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Provider Practice Location Address
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Address Line | 1478 HIGHLAND AVE SUITE A
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City | MELBOURNE
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State | FL
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Zip | 32935-6561
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Country | US
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Telephone | 321-242-2026
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Fax | 321-242-2423
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Provider Business Mailing Address
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Address Line | 1478 HIGHLAND AVE SUITE A
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City | MELBOURNE
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State | FL
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Zip | 32935-6561
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Country | US
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Telephone | 321-242-2026
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Fax | 321-242-2423
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Authorized Official
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Title or Position | MEDICAL DOCTOR
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Name | THOMAS C TEATHER
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Credential | MD
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Telephone | 321-242-2026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | ME66195
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License Number State | FL
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