Provider Demographics
NPI:1205185469
Name:DR. MEDINA'S OPTICAL, LLC.
Entity Type:Organization
Organization Name:DR. MEDINA'S OPTICAL, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ARIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDINA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-233-1330
Mailing Address - Street 1:8247 SW 124TH ST
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5900
Mailing Address - Country:US
Mailing Address - Phone:305-233-1330
Mailing Address - Fax:305-233-1362
Practice Address - Street 1:8247 SW 124TH ST
Practice Address - Street 2:
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-5900
Practice Address - Country:US
Practice Address - Phone:305-233-1330
Practice Address - Fax:305-233-1362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-04
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4155261QP2300X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No332H00000XSuppliersEyewear Supplier