Basic Information
| Provider Information | |||||||||
| NPI: | 1568766020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE EXPRESS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 1ST ST N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338814537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632998908 | ||||||||
| FaxNumber: | 8635952838 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E CENTRAL AVE | ||||||||
| Address2: | OPTICAL SUITE | ||||||||
| City: | WINTER HAVEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338803053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8632998908 | ||||||||
| FaxNumber: | 8635952838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2010 | ||||||||
| LastUpdateDate: | 12/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8632998908 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | OPC931 | FL | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 01 | FL | MEDICARE DME | OTHER | PENDING | 05 | FL | MEDICAID |