Provider Demographics
NPI:1861797482
Name:BIRD ROAD OPTICAL, INC.
Entity type:Organization
Organization Name:BIRD ROAD OPTICAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DORA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-223-6142
Mailing Address - Street 1:8485 SW 40TH ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-3244
Mailing Address - Country:US
Mailing Address - Phone:305-223-6142
Mailing Address - Fax:305-552-0824
Practice Address - Street 1:8485 SW 40TH ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-3244
Practice Address - Country:US
Practice Address - Phone:305-223-6142
Practice Address - Fax:305-552-0824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-12
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
FLOE879332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332H00000XSuppliersEyewear Supplier
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty