Provider Demographics
NPI:1952494700
Name:TITUSVILLE OPTICAL INC.
Entity Type:Organization
Organization Name:TITUSVILLE OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BRESSETTE
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:321-383-1267
Mailing Address - Street 1:1917 KNOX MCRAE DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780
Mailing Address - Country:US
Mailing Address - Phone:321-383-1267
Mailing Address - Fax:321-567-0999
Practice Address - Street 1:1917 KNOX MCRAE DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780
Practice Address - Country:US
Practice Address - Phone:321-383-1267
Practice Address - Fax:321-567-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3755332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD7802OtherBLUE CROSS BLUE SHIELD
FL1156910001Medicare ID - Type Unspecified