Provider Demographics
NPI:1164425229
Name:FIRST IMAGE OPTICAL LC
Entity Type:Organization
Organization Name:FIRST IMAGE OPTICAL LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:844-377-6468
Mailing Address - Street 1:17562 HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6711
Mailing Address - Country:US
Mailing Address - Phone:352-735-2020
Mailing Address - Fax:352-735-3233
Practice Address - Street 1:17562 HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6711
Practice Address - Country:US
Practice Address - Phone:352-735-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
FL0656250005332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
D7017Medicare ID - Type Unspecified
FL0656240001Medicare NSC