Provider Demographics
NPI:1134249410
Name:MANDARIN EYECARE ASSOC, INC
Entity type:Organization
Organization Name:MANDARIN EYECARE ASSOC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HATHY
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:904-292-3975
Mailing Address - Street 1:11111 SAN JOSE BLVD
Mailing Address - Street 2:SUITE 44
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-7946
Mailing Address - Country:US
Mailing Address - Phone:904-292-3975
Mailing Address - Fax:904-292-5322
Practice Address - Street 1:11111 SAN JOSE BLVD
Practice Address - Street 2:SUITE 44
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-7946
Practice Address - Country:US
Practice Address - Phone:904-292-3975
Practice Address - Fax:904-292-5322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL3574332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1284350001Medicare ID - Type Unspecified