Provider Demographics
NPI:1265908578
Name:VIP EYE CARE AND OPTICAL BOUTIQUE AT CARILLON LLC
Entity type:Organization
Organization Name:VIP EYE CARE AND OPTICAL BOUTIQUE AT CARILLON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENRI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-894-0500
Mailing Address - Street 1:12425 28TH ST N STE 103
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-1826
Mailing Address - Country:US
Mailing Address - Phone:727-295-0500
Mailing Address - Fax:
Practice Address - Street 1:12425 28TH ST N STE 103
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1826
Practice Address - Country:US
Practice Address - Phone:727-295-0500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-15
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty