MEDICARE: EYESAVERS EYEWEAR INC

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	156FX1800X	Optician	FL2073	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4697730001	OTHER	FL	DMERC
2	FL2073	OTHER	FL	EYEMED VISION CARE

General Provider Information

NPI Number	:	1164550257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYESAVERS EYEWEAR INC

Provider Business Mailing Address
First Line	:	11951 SOUTHERN BLVD
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-7619
Country	:	US
Telephone Number	:	561-514-1865
Fax Number	:	561-514-1855

Provider Business Practice Location Address
First Line	:	11951 SOUTHERN BLVD
Second Line	:
City	:	ROYAL PALM BEACH
State	:	FL
Zip	:	33411-7619
Country	:	US
Telephone Number	:	561-514-1865
Fax Number	:	561-514-1855

Authorized Official
Title or Position	:	OWNER OPTICIAN
Name	:	MR. MICHAEL MAINELLA
Credential	:
Telephone Number	:	561-514-1865

Provider Enumeration Date	:	03/01/2007
Last Update Date	:	08/22/2020

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