Provider Demographics
NPI:1861661175
Name:LAURIE S MCCONNELL OD PA
Entity Type:Organization
Organization Name:LAURIE S MCCONNELL OD PA
Other - Org Name:PRIVATE EYES OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:SEBRING
Authorized Official - Last Name:MCCONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:561-746-5088
Mailing Address - Street 1:235 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-2701
Mailing Address - Country:US
Mailing Address - Phone:561-746-5088
Mailing Address - Fax:561-746-5989
Practice Address - Street 1:235 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:TEQUESTA
Practice Address - State:FL
Practice Address - Zip Code:33469-2701
Practice Address - Country:US
Practice Address - Phone:561-746-5088
Practice Address - Fax:561-746-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOB 2812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621128300Medicaid
FLK7388AMedicare PIN
FL5288410001Medicare NSC