Provider Demographics
NPI:1730639592
Name:FIRST COAST OPTICAL LLC
Entity Type:Organization
Organization Name:FIRST COAST OPTICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-272-7626
Mailing Address - Street 1:179 COLLEGE DR STE 17
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32065-7690
Mailing Address - Country:US
Mailing Address - Phone:904-272-7626
Mailing Address - Fax:
Practice Address - Street 1:179 COLLEGE DR STE 17
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32065-7690
Practice Address - Country:US
Practice Address - Phone:904-272-7626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty