MEDICARE: OCULAR PROSTHETICS LAB 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	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	M2133	OTHER	FL	BCBS PROVIDER NUMBER
2	NA691	OTHER	FL	WELLCARE INS.

General Provider Information

NPI Number	:	1942429154
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OCULAR PROSTHETICS LAB INC

Provider Business Mailing Address
First Line	:	10 SOUTH BUMBY AVE
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32803-4434
Country	:	US
Telephone Number	:	407-246-5451
Fax Number	:	407-246-0222

Provider Business Practice Location Address
First Line	:	2845 N HARBOR CITY BLVD STE 2-3
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32935-6217
Country	:	US
Telephone Number	:	321-259-3847
Fax Number	:	407-246-0222

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	JAMES RICHARD BOWEN JR.
Credential	:	B.C.O, B.A.D.O.
Telephone Number	:	321-259-3847

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	06/28/2021

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