Provider Demographics
NPI:1700379385
Name:CHILDREN'S EYEWEAR CENTER, INC
Entity Type:Organization
Organization Name:CHILDREN'S EYEWEAR CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:MANDESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-234-5788
Mailing Address - Street 1:540 GOLDENMOSS LOOP
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4783
Mailing Address - Country:US
Mailing Address - Phone:407-234-5788
Mailing Address - Fax:
Practice Address - Street 1:1717 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806
Practice Address - Country:US
Practice Address - Phone:407-422-6798
Practice Address - Fax:407-992-7053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-08
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3019156FX1800X
332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100145900Medicaid