Provider Demographics
NPI:1215052477
Name:FADEA INC
Entity type:Organization
Organization Name:FADEA INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:PLUMB
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:863-413-0200
Mailing Address - Street 1:1371 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-7964
Mailing Address - Country:US
Mailing Address - Phone:863-413-0200
Mailing Address - Fax:863-413-0227
Practice Address - Street 1:1371 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-7964
Practice Address - Country:US
Practice Address - Phone:863-413-0200
Practice Address - Fax:863-413-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO4437156FX1800X
FLDO 5653156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39-80132227906OtherSALES TAX ID #
FL223338OtherEYEMED VISION CARE
FL=========OtherTAX ID #