Provider Demographics
NPI:1427255918
Name:INLET OPTICAL BOUTIQUE INC
Entity type:Organization
Organization Name:INLET OPTICAL BOUTIQUE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:HANNAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-746-5910
Mailing Address - Street 1:467 NE 10TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-2937
Mailing Address - Country:US
Mailing Address - Phone:561-395-2671
Mailing Address - Fax:
Practice Address - Street 1:103 S US HWY 1
Practice Address - Street 2:SUITE B2
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477
Practice Address - Country:US
Practice Address - Phone:561-746-5910
Practice Address - Fax:561-746-3268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO1417152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1165790001Medicare NSC