Provider Demographics
NPI:1871686667
Name:PHYSICIANS OPTICAL LAB INC
Entity type:Organization
Organization Name:PHYSICIANS OPTICAL LAB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-727-2020
Mailing Address - Street 1:502 E NEW HAVE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-5427
Mailing Address - Country:US
Mailing Address - Phone:321-722-3715
Mailing Address - Fax:321-722-3187
Practice Address - Street 1:502 E NEW HAVE AVE
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-5427
Practice Address - Country:US
Practice Address - Phone:321-722-3715
Practice Address - Fax:321-722-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0691190002Medicare ID - Type Unspecified