Provider Demographics
NPI:1912190919
Name:ROYAL PALM OPTICAL, INC.
Entity Type:Organization
Organization Name:ROYAL PALM OPTICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRSCH
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:561-912-0800
Mailing Address - Street 1:17940 MILITARY TRL
Mailing Address - Street 2:SUITE 400
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2499
Mailing Address - Country:US
Mailing Address - Phone:561-912-0800
Mailing Address - Fax:
Practice Address - Street 1:17940 MILITARY TRL
Practice Address - Street 2:SUITE 400
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2499
Practice Address - Country:US
Practice Address - Phone:561-912-0800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL3281332H00000X
FLFL5348332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5967180001Medicare NSC