Provider Demographics
NPI:1619393915
Name:AMELIA ISLAND OPTICS, LLC
Entity Type:Organization
Organization Name:AMELIA ISLAND OPTICS, LLC
Other - Org Name:EYE ENVY OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROCKATONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-277-2779
Mailing Address - Street 1:1480 SADLER RD
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-4426
Mailing Address - Country:US
Mailing Address - Phone:904-261-5955
Mailing Address - Fax:904-261-5956
Practice Address - Street 1:1523 SADLER RD
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-4467
Practice Address - Country:US
Practice Address - Phone:904-261-5955
Practice Address - Fax:904-261-5956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1462152W00000X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20335EMedicare UPIN