Provider Demographics
NPI:1356489918
Name:20/20 EYEGLASS SUPERSTORE, INC.
Entity Type:Organization
Organization Name:20/20 EYEGLASS SUPERSTORE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:UCCI
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC NCLE
Authorized Official - Phone:407-767-5600
Mailing Address - Street 1:1555 N. SEMORAN BLVD.
Mailing Address - Street 2:SUITE 1221
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792
Mailing Address - Country:US
Mailing Address - Phone:407-767-5600
Mailing Address - Fax:407-331-0277
Practice Address - Street 1:1555 N. SEMORAN BLVD.
Practice Address - Street 2:SUITE 1221
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792
Practice Address - Country:US
Practice Address - Phone:407-767-5600
Practice Address - Fax:407-331-0277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0844152W00000X
FLDO 5119156FC0801X, 156FX1800X
FLDO 2187156FC0801X, 156FX1800X
FLOE 874332H00000X
FLOE874332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20186OtherBLUE CROSS BLUE SHIELD
FL10654OtherSPECTERA
FLFL0844OtherEYEMED