Provider Demographics
NPI:1194174516
Name:SHANNON OPTOMETRY P.A.
Entity type:Organization
Organization Name:SHANNON OPTOMETRY P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:561-964-0220
Mailing Address - Street 1:10857 SUNSET RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33473-4851
Mailing Address - Country:US
Mailing Address - Phone:561-964-0220
Mailing Address - Fax:954-436-2332
Practice Address - Street 1:3345 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-3020
Practice Address - Country:US
Practice Address - Phone:561-964-0220
Practice Address - Fax:561-364-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3398152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicare PIN