Basic Information
| Provider Information | |||||||||
| NPI: | 1841582525 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTICAL RETAIL ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHWEST FLORIDA VISION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5113 N DAVIS HWY | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505493450 | ||||||||
| FaxNumber: | 8504976219 | ||||||||
| Practice Location | |||||||||
| Address1: | 5113 N DAVIS HWY | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325032035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505493450 | ||||||||
| FaxNumber: | 8504976219 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2011 | ||||||||
| LastUpdateDate: | 12/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | SPEAR | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 8505493450 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | |||||||||
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 | 003669300 | 05 | FL | MEDICAID |