Provider Demographics
NPI:1134589732
Name:DRIFTWOOD VISION CENTER
Entity type:Organization
Organization Name:DRIFTWOOD VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:C
Authorized Official - Last Name:REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-783-8820
Mailing Address - Street 1:1221 S. PATRICK DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PATRICK AIR FORCE BASE
Mailing Address - State:FL
Mailing Address - Zip Code:32925
Mailing Address - Country:US
Mailing Address - Phone:321-783-8820
Mailing Address - Fax:
Practice Address - Street 1:1221 S PATRICK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:PATRICK AIR FORCE BASE
Practice Address - State:FL
Practice Address - Zip Code:32925-3623
Practice Address - Country:US
Practice Address - Phone:321-783-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-25
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3269152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL20933OtherBCBS
FLU78190Medicare UPIN
FLE3434Medicare UPIN