Provider Demographics
NPI:1841478484
Name:UMATILLA OPTICAL & HEARING AID CENTER INC
Entity type:Organization
Organization Name:UMATILLA OPTICAL & HEARING AID CENTER INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTONE
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:352-669-6888
Mailing Address - Street 1:570 HATFIELD DR
Mailing Address - Street 2:
Mailing Address - City:UMATILLA
Mailing Address - State:FL
Mailing Address - Zip Code:32784-8986
Mailing Address - Country:US
Mailing Address - Phone:352-669-6888
Mailing Address - Fax:352-669-1015
Practice Address - Street 1:570 HATFIELD DR
Practice Address - Street 2:
Practice Address - City:UMATILLA
Practice Address - State:FL
Practice Address - Zip Code:32784-8986
Practice Address - Country:US
Practice Address - Phone:352-669-6888
Practice Address - Fax:352-669-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS2700332S00000X
FLDO3146332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No332S00000XSuppliersHearing Aid Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL086623700Medicaid
FL610136400Medicaid
FL10449OtherCMS PEDICARE
FL0647230001OtherMEDICARE P TAN NUMBER
FL2100002OtherUHC
FLFL3146OtherEYEMED
FL086623701Medicaid