Basic Information
| Provider Information | |||||||||
| NPI: | 1831853845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH FLORIDA VISION SERVICES, INC. | ||||||||
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| 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: | 6618 ATLANTIC AVE | ||||||||
| Address2: | |||||||||
| City: | DELRAY BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334461616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5614985007 | ||||||||
| FaxNumber: | 5614963088 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2021 | ||||||||
| LastUpdateDate: | 10/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | COPPOLA | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9549172337 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTH FLORIDA VISION SERVICES, INC. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 10/29/2021 | ||||||||
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 | 621006606 | 05 | FL | MEDICAID |