Provider Demographics
NPI:1124176698
Name:FOR EYES OPTICAL OF PA
Entity type:Organization
Organization Name:FOR EYES OPTICAL OF PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-557-9004
Mailing Address - Street 1:3601 SW 160TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6312
Mailing Address - Country:US
Mailing Address - Phone:305-557-9004
Mailing Address - Fax:
Practice Address - Street 1:9 W MADISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602
Practice Address - Country:US
Practice Address - Phone:312-857-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2018-06-21
Deactivation Date:2013-07-10
Deactivation Code:
Reactivation Date:2013-08-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0682000034Medicare NSC