Provider Demographics
NPI:1518097518
Name:WARD, TRACY ANNE (OWNER OPTICAL SHOP)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ANNE
Last Name:WARD
Suffix:
Gender:F
Credentials:OWNER OPTICAL SHOP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1815 E COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-3760
Mailing Address - Country:US
Mailing Address - Phone:954-491-2722
Mailing Address - Fax:954-491-7977
Practice Address - Street 1:1815 E COMMERCIAL BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3760
Practice Address - Country:US
Practice Address - Phone:954-491-2722
Practice Address - Fax:954-491-7977
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO 2452156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician