Basic Information
| Provider Information | |||||||||
| NPI: | 1104046267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OPTICAL OUTLET INC IV | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 SE PORT ST LUCIE BLVD | ||||||||
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| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728781414 | ||||||||
| FaxNumber: | 7728780118 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 SE PORT ST LUCIE BLVD | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34984 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7728781414 | ||||||||
| FaxNumber: | 7728780118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ARTEAGA | ||||||||
| AuthorizedOfficialFirstName: | LORRAINE | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED OPTICIAN OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7728781414 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | DO3422 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.