Provider Demographics
NPI:1689607467
Name:EYEWEAR BOUTIQUE, INC
Entity Type:Organization
Organization Name:EYEWEAR BOUTIQUE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:PERICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-372-1311
Mailing Address - Street 1:2020 SEVEN SPRINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655
Mailing Address - Country:US
Mailing Address - Phone:727-372-1311
Mailing Address - Fax:727-372-1972
Practice Address - Street 1:2020 SEVEN SPRINGS BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655
Practice Address - Country:US
Practice Address - Phone:727-372-1311
Practice Address - Fax:727-372-1972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1038280001Medicare ID - Type Unspecified