MEDICARE: LOW VISION CENTER OF NORTHEAST FLORIDA 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	152W00000X	Optometrist	OPC4045	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE3862	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	28569	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1235329848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOW VISION CENTER OF NORTHEAST FLORIDA INC

Provider Business Mailing Address
First Line	:	2519 RIVERSIDE AVENUE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4710
Country	:	US
Telephone Number	:	904-389-9989
Fax Number	:	904-389-1060

Provider Business Practice Location Address
First Line	:	2519 RIVERSIDE AVENUE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-4710
Country	:	US
Telephone Number	:	904-389-9989
Fax Number	:	904-389-1060

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	DR. TIFFANY E OWENS
Credential	:	OD
Telephone Number	:	904-389-9989

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	06/25/2008

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