Provider Demographics
NPI:1699826552
Name:EYE-STYLE OPTICAL
Entity Type:Organization
Organization Name:EYE-STYLE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JADE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:386-446-4210
Mailing Address - Street 1:7 OLD KINGS RD N STE 32
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32137-8247
Mailing Address - Country:US
Mailing Address - Phone:386-446-4210
Mailing Address - Fax:386-445-7309
Practice Address - Street 1:7 OLD KINGS RD N STE 32
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32137-8247
Practice Address - Country:US
Practice Address - Phone:386-446-4210
Practice Address - Fax:386-445-7309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3668156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOP0463OtherEYEMED PROVIDER ID#
FL0682360001Medicare ID - Type UnspecifiedMEDICARE ID #