MEDICARE: BEACH VISION HOLDINGS, PA

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	OPC 1689	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346516747
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACH VISION HOLDINGS, PA

Provider Business Mailing Address
First Line	:	103 FAULKNER ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7017
Country	:	US
Telephone Number	:	396-423-7788
Fax Number	:	386-423-0035

Provider Business Practice Location Address
First Line	:	103 FAULKNER ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7017
Country	:	US
Telephone Number	:	396-423-7788
Fax Number	:	386-423-0035

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	SUSAN SIMPSON SULLENBERGER
Credential	:
Telephone Number	:	386-547-1549

Provider Enumeration Date	:	03/29/2012
Last Update Date	:	08/20/2024

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