Provider Demographics
NPI:1376751826
Name:FOR EYES OPTICAL OF PA
Entity Type:Organization
Organization Name:FOR EYES OPTICAL OF PA
Other - Org Name:FOR EYES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HANS
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DER HEYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-557-9004
Mailing Address - Street 1:3601 SW 160TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6308
Mailing Address - Country:US
Mailing Address - Phone:305-557-9004
Mailing Address - Fax:855-881-9434
Practice Address - Street 1:3690 KING ST
Practice Address - Street 2:SUITE K & L
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1921
Practice Address - Country:US
Practice Address - Phone:703-552-6352
Practice Address - Fax:703-933-6327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2017-03-30
Deactivation Date:2013-07-11
Deactivation Code:
Reactivation Date:2013-08-01
Provider Licenses
StateLicense IDTaxonomies
VA1101003519332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0682000050Medicare NSC