Basic Information
Provider Information | |||||||||
NPI: | 1326702341 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTH FLORIDA VISION SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2900 W CYPRESS CREEK RD STE 4 | ||||||||
Address2: |   | ||||||||
City: | FT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 333091715 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9549172337 | ||||||||
FaxNumber: | 9549798988 | ||||||||
Practice Location | |||||||||
Address1: | 9851 S MILITARY TRL | ||||||||
Address2: |   | ||||||||
City: | BOYNTON BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 334363237 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5617428701 | ||||||||
FaxNumber: | 5617424212 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/26/2021 | ||||||||
LastUpdateDate: | 10/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | COPPOLA | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: | C. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 9549172337 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SOUTH FLORIDA VISION SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: | 10/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 621006605 | 05 | FL |   | MEDICAID |