Provider Demographics
NPI:1982086211
Name:FLORIDA EYE DOCTORS, INC
Entity Type:Organization
Organization Name:FLORIDA EYE DOCTORS, INC
Other - Org Name:FLORIDA EYE DOCTORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:FLORENCIO
Authorized Official - Last Name:DECANIO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:561-665-0437
Mailing Address - Street 1:4174 PALO VERDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-3053
Mailing Address - Country:US
Mailing Address - Phone:561-734-2172
Mailing Address - Fax:561-734-2172
Practice Address - Street 1:1000 NORTH CONGRESS AVENUE SUITE 150
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-3337
Practice Address - Country:US
Practice Address - Phone:561-734-2172
Practice Address - Fax:561-734-2847
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLORIDA EYE DOCTORS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1598152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0782009-00Medicaid
FL0782009-00Medicaid