MEDICARE: EYE-SITE OF BOYNTON BEACH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332H00000X	Eyewear Supplier	5095	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5095	OTHER	FL	FLORIDA OPTICIANS

General Provider Information

NPI Number	:	1003280306
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE-SITE OF BOYNTON BEACH

Provider Business Mailing Address
First Line	:	6641 W BOYNTON BEACH BLVD
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437
Country	:	US
Telephone Number	:	561-738-0111
Fax Number	:	561-735-9359

Provider Business Practice Location Address
First Line	:	6641 W BOYNTON BEACH BLVD
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33437-3527
Country	:	US
Telephone Number	:	561-738-0111
Fax Number	:	561-735-9359

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DAVID MILES THOMAS
Credential	:	L.D.O
Telephone Number	:	561-738-0111

Provider Enumeration Date	:	11/24/2015
Last Update Date	:	11/24/2015

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