Provider Demographics
NPI:1023279460
Name:MAYFAIR REGENCY INC.
Entity type:Organization
Organization Name:MAYFAIR REGENCY INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LOCKERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:904-725-2020
Mailing Address - Street 1:9430 ARLINGTON EXPY
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-8231
Mailing Address - Country:US
Mailing Address - Phone:904-725-2020
Mailing Address - Fax:
Practice Address - Street 1:9430 ARLINGTON EXPY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-8231
Practice Address - Country:US
Practice Address - Phone:904-725-2020
Practice Address - Fax:904-725-4262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO9859332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0789680001OtherOPTICAL FILL OUT FORMS 1500 FOR CUSTOMERS