MEDICARE: IDEAL OPTICAL 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D5664	OTHER		FLORIDA BS

General Provider Information

NPI Number	:	1508920299
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL OPTICAL INC

Provider Business Mailing Address
First Line	:	6873A NORTH 9TH AVE
Second Line	:	IDEAL OPTICAL INC
City	:	PENSACOLA
State	:	FL
Zip	:	32504-7349
Country	:	US
Telephone Number	:	850-477-0582
Fax Number	:

Provider Business Practice Location Address
First Line	:	6873A NORTH 9TH AVE
Second Line	:	IDEAL OPTICAL INC
City	:	PENSACOLA
State	:	FL
Zip	:	32504-7349
Country	:	US
Telephone Number	:	850-477-0582
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. FRED L PUTNAM
Credential	:	OPTICIAN
Telephone Number	:	850-477-0582

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	08/22/2020

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Directions to “IDEAL OPTICAL INC ” Practice Location

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