Provider Demographics
NPI:1083914808
Name:A. L. HARRELL,III, O.D., P.A.
Entity Type:Organization
Organization Name:A. L. HARRELL,III, O.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:HARRELL
Authorized Official - Suffix:III
Authorized Official - Credentials:OD
Authorized Official - Phone:561-798-8282
Mailing Address - Street 1:11924 W FOREST HILL BLVD
Mailing Address - Street 2:31
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6256
Mailing Address - Country:US
Mailing Address - Phone:561-798-8282
Mailing Address - Fax:561-798-2840
Practice Address - Street 1:11924 W FOREST HILL BLVD
Practice Address - Street 2:31
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6256
Practice Address - Country:US
Practice Address - Phone:561-798-8282
Practice Address - Fax:561-798-2840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOP 1746152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0776020002OtherDMERC
FL078294701Medicaid
FL078294701Medicaid
FLET243AMedicare PIN