Provider Demographics
NPI:1518060771
Name:FOR EYES OPTICAL, INC. OF PENNSYLVANIA
Entity Type:Organization
Organization Name:FOR EYES OPTICAL, INC. OF PENNSYLVANIA
Other - Org Name:FOR EYES OPTICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-557-9004
Mailing Address - Street 1:3601 SW 160TH AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6308
Mailing Address - Country:US
Mailing Address - Phone:305-557-9004
Mailing Address - Fax:
Practice Address - Street 1:600 BROADWAY STE C
Practice Address - Street 2:
Practice Address - City:SAUGUS
Practice Address - State:MA
Practice Address - Zip Code:01906
Practice Address - Country:US
Practice Address - Phone:781-231-2288
Practice Address - Fax:781-231-1235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-02-21
Deactivation Date:2013-07-11
Deactivation Code:
Reactivation Date:2013-08-02
Provider Licenses
StateLicense IDTaxonomies
MA5360332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0682000059Medicare ID - Type Unspecified