Basic Information
Provider Information | |||||||||
NPI: | 1396313722 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEAUMONT | ||||||||
FirstName: | COURTNEY | ||||||||
MiddleName: | LYNN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SANDIFER | ||||||||
OtherFirstName: | COURTNEY | ||||||||
OtherMiddleName: | LYNN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 407 AVENUE K SE | ||||||||
Address2: |   | ||||||||
City: | WINTER HAVEN | ||||||||
State: | FL | ||||||||
PostalCode: | 338804126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8632943504 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 407 AVENUE K SE | ||||||||
Address2: |   | ||||||||
City: | WINTER HAVEN | ||||||||
State: | FL | ||||||||
PostalCode: | 338804126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8632943504 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2021 | ||||||||
LastUpdateDate: | 07/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5928 | FL | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.