Provider Demographics
NPI:1275609471
Name:BEACH DRIVE OPTICAL
Entity Type:Organization
Organization Name:BEACH DRIVE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:727-823-2773
Mailing Address - Street 1:238 BEACH DR NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-3414
Mailing Address - Country:US
Mailing Address - Phone:727-823-2773
Mailing Address - Fax:727-823-9039
Practice Address - Street 1:238 BEACH DR NE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-3414
Practice Address - Country:US
Practice Address - Phone:727-823-2773
Practice Address - Fax:727-823-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4546156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0934640001Medicare ID - Type Unspecified