Basic Information
Provider Information | |||||||||
NPI: | 1386159358 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CAPSTONE EYE CARE GROUP OF FLORIDA LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PEARLE VISION - WINTER PARK | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 E MEMORIAL RD STE A4 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731142218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3108687322 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 110 S ORLANDO AVE STE 11 | ||||||||
Address2: |   | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 327893656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4075719165 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/12/2017 | ||||||||
LastUpdateDate: | 12/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BUTCHER | ||||||||
AuthorizedOfficialFirstName: | JEFF | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4053172140 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CAPSTONE EYE CARE GROUP OF FLORIDA LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | OD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X |   |   | Y |   | Suppliers | Eyewear Supplier (Equipment, not the service) |   |
No ID Information.