Provider Demographics
NPI:1104046267
Name:OPTICAL OUTLET INC IV
Entity type:Organization
Organization Name:OPTICAL OUTLET INC IV
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:O
Authorized Official - Last Name:ARTEAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-878-1414
Mailing Address - Street 1:319 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34984
Mailing Address - Country:US
Mailing Address - Phone:772-878-1414
Mailing Address - Fax:772-878-0118
Practice Address - Street 1:319 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984
Practice Address - Country:US
Practice Address - Phone:772-878-1414
Practice Address - Fax:772-878-0118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3422156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty