Provider Demographics
NPI:1154867554
Name:CABANA EYES OPTICAL
Entity Type:Organization
Organization Name:CABANA EYES OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ VISUAL RESOURCE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:LDO
Authorized Official - Phone:850-758-0474
Mailing Address - Street 1:4100 S FERDON BLVD
Mailing Address - Street 2:SUITE B5
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-5252
Mailing Address - Country:US
Mailing Address - Phone:850-306-2580
Mailing Address - Fax:850-423-0142
Practice Address - Street 1:4100 S FERDON BLVD
Practice Address - Street 2:SUITE B5
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-5252
Practice Address - Country:US
Practice Address - Phone:850-758-0474
Practice Address - Fax:850-826-0057
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARD MITCHELL JR
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-01-10
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003088900Medicaid