Basic Information
| Provider Information | |||||||||
| NPI: | 1245540509 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE EXPRESS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 1ST ST N | ||||||||
| Address2: | STE 100 | ||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632998908 | ||||||||
| FaxNumber: | 8635952838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1040 CYPRESS PKWY | ||||||||
| Address2: | |||||||||
| City: | POINCIANA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347593328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8638756568 | ||||||||
| FaxNumber: | 8632991061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2010 | ||||||||
| LastUpdateDate: | 07/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8632998908 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC931 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1326032293 | 01 | FL | NPI | OTHER | 1235228669 | 01 | FL | NPI | OTHER | 1831252089 | 01 | FL | NPI | OTHER | 1174517940 | 01 | FL | NPI | OTHER | 1952395725 | 01 | FL | NPI | OTHER | 1295729069 | 01 | FL | NPI | OTHER | 10533005821 | 01 | FL | NPI | OTHER |