Provider Demographics
NPI:1720100399
Name:P D LAB INC
Entity Type:Organization
Organization Name:P D LAB INC
Other - Org Name:EYE WONDERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-304-1234
Mailing Address - Street 1:6169 JOG RD
Mailing Address - Street 2:STE A3
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-6579
Mailing Address - Country:US
Mailing Address - Phone:561-304-1234
Mailing Address - Fax:561-304-1254
Practice Address - Street 1:6169 JOG RD
Practice Address - Street 2:STE A3
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-6579
Practice Address - Country:US
Practice Address - Phone:561-304-1234
Practice Address - Fax:561-304-1254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO1062156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001904700Medicaid
FL001904700Medicaid