Provider Demographics
NPI:1982621884
Name:ECSA OPTICAL COMPANY, LLC
Entity Type:Organization
Organization Name:ECSA OPTICAL COMPANY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:HUND
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:904-829-2286
Mailing Address - Street 1:1400 US HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-4211
Mailing Address - Country:US
Mailing Address - Phone:904-829-2286
Mailing Address - Fax:904-829-5447
Practice Address - Street 1:1400 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-4211
Practice Address - Country:US
Practice Address - Phone:904-829-2286
Practice Address - Fax:904-829-5447
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68633332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5750850001Medicare NSC