Provider Demographics
NPI:1396409314
Name:SOUTH FLORIDA VISION SERVICES, INC.
Entity Type:Organization
Organization Name:SOUTH FLORIDA VISION SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:C
Authorized Official - Last Name:COPPOLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-917-2337
Mailing Address - Street 1:2900 W CYPRESS CREEK RD STE 4
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-1715
Mailing Address - Country:US
Mailing Address - Phone:954-917-2337
Mailing Address - Fax:954-979-8988
Practice Address - Street 1:143 N POWERLINE RD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-8037
Practice Address - Country:US
Practice Address - Phone:954-429-9600
Practice Address - Fax:954-429-9956
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH FLORIDA VISION SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621006607Medicaid