Provider Demographics
NPI:1205829033
Name:BUENA VISTA EYELAND INC
Entity Type:Organization
Organization Name:BUENA VISTA EYELAND INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLO
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:FODOR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:772-388-9330
Mailing Address - Street 1:1619 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3834
Mailing Address - Country:US
Mailing Address - Phone:772-388-9330
Mailing Address - Fax:772-388-3036
Practice Address - Street 1:1619 US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3834
Practice Address - Country:US
Practice Address - Phone:772-388-9330
Practice Address - Fax:772-388-3036
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC003794152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620854100Medicaid
FL620854100Medicaid
FL5303580001Medicare NSC
FL23010AMedicare ID - Type Unspecified