Provider Demographics
NPI:1215287958
Name:INNOVATIVE VISION & WELLNESS
Entity type:Organization
Organization Name:INNOVATIVE VISION & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRYAN
Authorized Official - Suffix:
Authorized Official - Credentials:ODPA
Authorized Official - Phone:305-652-5277
Mailing Address - Street 1:20354 NW 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33169-2503
Mailing Address - Country:US
Mailing Address - Phone:305-652-5277
Mailing Address - Fax:305-652-8330
Practice Address - Street 1:20354 NW 2ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33169-2503
Practice Address - Country:US
Practice Address - Phone:305-652-5277
Practice Address - Fax:305-652-8330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-10
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2907152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20667Medicare PIN