Provider Demographics
NPI:1053469601
Name:FOR EYES OPTICAL OF PA
Entity Type:Organization
Organization Name:FOR EYES OPTICAL OF PA
Other - Org Name:FOR EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-557-9004
Mailing Address - Street 1:3601 SW 160TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6312
Mailing Address - Country:US
Mailing Address - Phone:305-557-9004
Mailing Address - Fax:
Practice Address - Street 1:1530 TORRENCE AVE
Practice Address - Street 2:
Practice Address - City:CALUMET CITY
Practice Address - State:IL
Practice Address - Zip Code:60409-5409
Practice Address - Country:US
Practice Address - Phone:708-868-5807
Practice Address - Fax:708-868-5840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2018-05-07
Deactivation Date:2013-07-11
Deactivation Code:
Reactivation Date:2013-08-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0682000022Medicare NSC