Provider Demographics
NPI:1629546007
Name:BLINKING OWL EYECARE LLC
Entity Type:Organization
Organization Name:BLINKING OWL EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FATEN
Authorized Official - Middle Name:
Authorized Official - Last Name:EDRISKHALAF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:786-452-6690
Mailing Address - Street 1:50 BISCAYNE BLVD APT 3602
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33132-2943
Mailing Address - Country:US
Mailing Address - Phone:786-452-6690
Mailing Address - Fax:
Practice Address - Street 1:5800 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-6102
Practice Address - Country:US
Practice Address - Phone:954-252-2583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty