MEDICARE: FOR EYES OPTICAL OF 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

General Provider Information

NPI Number	:	1861966848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOR EYES OPTICAL OF PA

Provider Business Mailing Address
First Line	:	3601 SW 160TH AVE STE 400
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33027-6312
Country	:	US
Telephone Number	:	305-557-9004
Fax Number	:

Provider Business Practice Location Address
First Line	:	122 BROADVIEW VILLAGE SQ
Second Line	:
City	:	BROADVIEW
State	:	IL
Zip	:	60155-4874
Country	:	US
Telephone Number	:	708-343-2020
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JOSE COSTA
Credential	:
Telephone Number	:	305-557-9004

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	01/14/2019

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