Provider Demographics
NPI:1497954697
Name:OPTICAL BOUTIQUE INC.
Entity Type:Organization
Organization Name:OPTICAL BOUTIQUE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:FARIAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-324-0490
Mailing Address - Street 1:901 NW 17TH ST
Mailing Address - Street 2:SUITE P
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1135
Mailing Address - Country:US
Mailing Address - Phone:305-324-0490
Mailing Address - Fax:305-324-9890
Practice Address - Street 1:901 NW 17TH ST
Practice Address - Street 2:SUITE P
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1135
Practice Address - Country:US
Practice Address - Phone:305-324-0490
Practice Address - Fax:305-324-9890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-17
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO2329156FX1800X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078328500Medicaid