Provider Demographics
NPI:1851575278
Name:THE EYEGLASS PLACE
Entity Type:Organization
Organization Name:THE EYEGLASS PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OPTTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LISSETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:RAKUSA
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:305-669-3890
Mailing Address - Street 1:430 S. DIXIE HWY
Mailing Address - Street 2:SUITE #5
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2273
Mailing Address - Country:US
Mailing Address - Phone:305-669-3890
Mailing Address - Fax:305-669-3935
Practice Address - Street 1:430 S DIXIE HWY
Practice Address - Street 2:SUITE #5
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2273
Practice Address - Country:US
Practice Address - Phone:305-669-3890
Practice Address - Fax:305-669-3935
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOE1503332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630399400Medicaid
FL630399400Medicaid