Provider Demographics
NPI:1528302510
Name:OPTOMETRY HOLDINGS, LLC
Entity type:Organization
Organization Name:OPTOMETRY HOLDINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NOEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-288-3032
Mailing Address - Street 1:13506 SUMMERPORT VILLAGE PKWY
Mailing Address - Street 2:#254
Mailing Address - City:WINDERMERE
Mailing Address - State:FL
Mailing Address - Zip Code:34786-7366
Mailing Address - Country:US
Mailing Address - Phone:954-288-3032
Mailing Address - Fax:954-491-6697
Practice Address - Street 1:5200 N FEDERAL HWY
Practice Address - Street 2:STUITE 4
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-3253
Practice Address - Country:US
Practice Address - Phone:954-491-6663
Practice Address - Fax:954-491-6667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3970152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU65034OtherMEDICARE PTAN