Provider Demographics
NPI:1841582525
Name:OPTICAL RETAIL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:OPTICAL RETAIL ASSOCIATES, LLC
Other - Org Name:NORTHWEST FLORIDA VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:H
Authorized Official - Last Name:SPEAR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-549-3450
Mailing Address - Street 1:5113 N DAVIS HWY
Mailing Address - Street 2:SUITE 11
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2035
Mailing Address - Country:US
Mailing Address - Phone:850-549-3450
Mailing Address - Fax:850-497-6219
Practice Address - Street 1:5113 N DAVIS HWY
Practice Address - Street 2:SUITE 11
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503-2035
Practice Address - Country:US
Practice Address - Phone:850-549-3450
Practice Address - Fax:850-497-6219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003669300Medicaid
FL003669300Medicaid