Provider Demographics
NPI:1386821379
Name:FAMILY VISION INSTITUTE OF SOUTH FLORIDA INC.
Entity Type:Organization
Organization Name:FAMILY VISION INSTITUTE OF SOUTH FLORIDA INC.
Other - Org Name:VISION SOURCE FORT LAUDERDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:CORNISH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-522-3918
Mailing Address - Street 1:640 N FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4686
Mailing Address - Country:US
Mailing Address - Phone:954-522-3918
Mailing Address - Fax:954-522-5137
Practice Address - Street 1:640 N FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-4686
Practice Address - Country:US
Practice Address - Phone:954-522-3918
Practice Address - Fax:954-522-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4217152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621267100Medicaid
FL621267100Medicaid