Provider Demographics
NPI:1215077557
Name:EYESUPPLY
Entity type:Organization
Organization Name:EYESUPPLY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:UCCI
Authorized Official - Suffix:
Authorized Official - Credentials:ABOC NCLE
Authorized Official - Phone:321-259-3935
Mailing Address - Street 1:785 N WICKHAM RD
Mailing Address - Street 2:STE. 106
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8857
Mailing Address - Country:US
Mailing Address - Phone:321-259-3935
Mailing Address - Fax:
Practice Address - Street 1:785 N WICKHAM RD
Practice Address - Street 2:STE. 106
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8857
Practice Address - Country:US
Practice Address - Phone:321-259-3935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2732152W00000X
FLDO5119156FC0801X, 156FX1800X
FLDO3652156FC0801X, 156FX1800X
FLOE1487332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens FitterGroup - Multi-Specialty
Not Answered156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Not Answered332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFL2732OtherEYEMED
FL29268OtherSPECTRA
FLFL5119OtherEYEMED