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General NPI Number Information
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NPI Number | 1922403005
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Entity Type | Organization
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Legal Business Name | COLLEGE EYECARE LLC
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Dates
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Enumeration Date | 10/30/2014
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Last Update Date | 10/30/2014
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Provider Practice Location Address
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Address Line | 11099 SW 10TH ST
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City | MIAMI
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State | FL
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Zip | 33199-0001
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Country | US
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Telephone | 305-348-8439
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Fax |
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Provider Business Mailing Address
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Address Line | 2984 ALAFAYA TRL # 1030
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City | OVIEDO
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State | FL
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Zip | 32765-7628
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Country | US
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Telephone | 352-409-5783
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. JOHN A CLARK
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Credential | O.D.
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Telephone | 352-409-5783
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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 | OPC 1726
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License Number State | FL
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