MEDICARE: EYESHOPPE OF ORLANDO, LLC

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	OE1930	FL

General Provider Information

NPI Number	:	1396049607
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYESHOPPE OF ORLANDO, LLC

Provider Business Mailing Address
First Line	:	10209 E COLONIAL DR
Second Line	:	130
City	:	ORLANDO
State	:	FL
Zip	:	32817-4306
Country	:	US
Telephone Number	:	407-382-7701
Fax Number	:	407-382-7702

Provider Business Practice Location Address
First Line	:	10209 E COLONIAL DR
Second Line	:	130
City	:	ORLANDO
State	:	FL
Zip	:	32817-4306
Country	:	US
Telephone Number	:	407-382-7701
Fax Number	:	407-382-7702

Authorized Official
Title or Position	:	MANAGER/OPTICIAN
Name	:	MR. ROBERT HERNANDEZ UYCOCO
Credential	:	OPTICIAN
Telephone Number	:	407-382-7701

Provider Enumeration Date	:	12/29/2010
Last Update Date	:	12/29/2010

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