Provider Demographics
NPI:1235317983
Name:OPTIQUE UNIQUE
Entity Type:Organization
Organization Name:OPTIQUE UNIQUE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:BARRY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:321-729-4340
Mailing Address - Street 1:880 N MIRAMAR AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3054
Mailing Address - Country:US
Mailing Address - Phone:321-729-4340
Mailing Address - Fax:
Practice Address - Street 1:880 N MIRAMAR AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-3054
Practice Address - Country:US
Practice Address - Phone:321-729-4340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2197332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1205950730Medicare UPIN
FL1235317983Medicare UPIN
FL1008290001Medicare NSC