Provider Demographics
NPI:1790922813
Name:20/20 CLUB
Entity Type:Organization
Organization Name:20/20 CLUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOE
Authorized Official - Last Name:NODLAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:561-784-2778
Mailing Address - Street 1:10155 OKEECHOBEE BLVD
Mailing Address - Street 2:OPTICAL
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-1404
Mailing Address - Country:US
Mailing Address - Phone:516-784-2778
Mailing Address - Fax:561-798-9409
Practice Address - Street 1:10155 OKEECHOBEE BLVD
Practice Address - Street 2:OPTICAL
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-1404
Practice Address - Country:US
Practice Address - Phone:516-784-2778
Practice Address - Fax:561-798-9409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-12
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4365152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty