Provider Demographics
NPI:1598981565
Name:HOMETOWN SPECS EMPORIUM, INC.
Entity Type:Organization
Organization Name:HOMETOWN SPECS EMPORIUM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:SMURR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:352-521-3011
Mailing Address - Street 1:13940 7TH ST
Mailing Address - Street 2:
Mailing Address - City:DADE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33525-4904
Mailing Address - Country:US
Mailing Address - Phone:352-521-3011
Mailing Address - Fax:352-521-7163
Practice Address - Street 1:13940 7TH ST
Practice Address - Street 2:
Practice Address - City:DADE CITY
Practice Address - State:FL
Practice Address - Zip Code:33525-4904
Practice Address - Country:US
Practice Address - Phone:352-521-3011
Practice Address - Fax:352-521-7163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20246OtherBCBS
4609006OtherAETNA
3943630001Medicare NSC
K1651Medicare PIN
4609006OtherAETNA