Provider Demographics
NPI:1386042026
Name:MAXIM-EYES OPTICAL, INC
Entity Type:Organization
Organization Name:MAXIM-EYES OPTICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DULCIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIFFNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-653-9661
Mailing Address - Street 1:2547 E STATE ROAD 60
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-3830
Mailing Address - Country:US
Mailing Address - Phone:813-653-9661
Mailing Address - Fax:813-657-4334
Practice Address - Street 1:2547 E STATE ROAD 60
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33594-3830
Practice Address - Country:US
Practice Address - Phone:813-653-9661
Practice Address - Fax:813-657-4334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2050152W00000X
FLDO4868156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630341200Medicaid
FL078763900Medicaid
FL078763900Medicaid