Provider Demographics
NPI:1508035007
Name:DAVALT OPTICAL INC
Entity Type:Organization
Organization Name:DAVALT OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAVALT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-353-6229
Mailing Address - Street 1:807 LOMAX ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3901
Mailing Address - Country:US
Mailing Address - Phone:904-353-6229
Mailing Address - Fax:
Practice Address - Street 1:807 LOMAX ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-3901
Practice Address - Country:US
Practice Address - Phone:904-353-6229
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
0873280001Medicare NSC