Provider Demographics
NPI:1083799134
Name:FOR EYES OPTICAL CO OF PENNSYLVANIA
Entity Type:Organization
Organization Name:FOR EYES OPTICAL CO OF PENNSYLVANIA
Other - Org Name:FOR EYES OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
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 1:8900 W BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-5815
Practice Address - Country:US
Practice Address - Phone:804-747-8843
Practice Address - Fax:804-346-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-02-26
Deactivation Date:2013-07-11
Deactivation Code:
Reactivation Date:2013-08-01
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA009281151Medicaid
VA0682000019Medicare NSC