MEDICARE: AMELIA ISLAND OPTICS, 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
2	152W00000X	Optometrist	OPC1462	FL

General Provider Information

NPI Number	:	1619393915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMELIA ISLAND OPTICS, LLC

Provider Business Mailing Address
First Line	:	1480 SADLER RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4426
Country	:	US
Telephone Number	:	904-261-5955
Fax Number	:	904-261-5956

Provider Business Practice Location Address
First Line	:	1523 SADLER RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4467
Country	:	US
Telephone Number	:	904-261-5955
Fax Number	:	904-261-5956

Authorized Official
Title or Position	:	OWNER
Name	:	ROCKATONIA BRADLEY
Credential	:
Telephone Number	:	904-277-2779

Provider Enumeration Date	:	03/11/2014
Last Update Date	:	12/16/2020

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