Provider Demographics
NPI:1255658316
Name:OPTICAL AT SOUTHPOINT
Entity Type:Organization
Organization Name:OPTICAL AT SOUTHPOINT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNST
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOLITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-398-2720
Mailing Address - Street 1:7051 SOUTHPOINT PKWY
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8713
Mailing Address - Country:US
Mailing Address - Phone:904-398-2720
Mailing Address - Fax:904-483-5640
Practice Address - Street 1:7051 SOUTHPOINT PKWY
Practice Address - Street 2:3RD FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8713
Practice Address - Country:US
Practice Address - Phone:904-398-2720
Practice Address - Fax:904-483-5640
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ERNST NICOLITZ, M.D., P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-04-29
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZME31869332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies