Provider Demographics
NPI:1720232648
Name:FOUR H OPTICAL
Entity Type:Organization
Organization Name:FOUR H OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUDE
Authorized Official - Middle Name:LUCILLE
Authorized Official - Last Name:HOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-377-0532
Mailing Address - Street 1:4605 NW 6TH ST
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32609-4197
Mailing Address - Country:US
Mailing Address - Phone:352-377-0532
Mailing Address - Fax:352-338-8001
Practice Address - Street 1:2441 NW 43RD ST
Practice Address - Street 2:SUITE 2C
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-7469
Practice Address - Country:US
Practice Address - Phone:352-377-0532
Practice Address - Fax:352-338-8001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-05
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5019156FX1800X
FL3940156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630303001Medicaid
FL0726750001Medicare NSC