Provider Demographics
NPI:1235329848
Name:LOW VISION CENTER OF NORTHEAST FLORIDA INC
Entity Type:Organization
Organization Name:LOW VISION CENTER OF NORTHEAST FLORIDA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:E
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-389-9989
Mailing Address - Street 1:2519 RIVERSIDE AVENUE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4710
Mailing Address - Country:US
Mailing Address - Phone:904-389-9989
Mailing Address - Fax:904-389-1060
Practice Address - Street 1:2519 RIVERSIDE AVENUE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4710
Practice Address - Country:US
Practice Address - Phone:904-389-9989
Practice Address - Fax:904-389-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4045152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE3862OtherRAILROAD MEDICARE
FL621075900Medicaid
FL28569OtherBCBS
DE3862OtherRAILROAD MEDICARE
FL621075900Medicaid
FLK9150Medicare UPIN