1871107805 NPI number — BETH A HEBERT LICENSED OPTICIAN

Table of content: BETH A HEBERT LICENSED OPTICIAN (NPI 1871107805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871107805 NPI number — BETH A HEBERT LICENSED OPTICIAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEBERT
Provider First Name:
BETH
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LICENSED OPTICIAN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871107805
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1298 SW HUNNICUT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT ST LUCIE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34953-5336
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-206-1086
Provider Business Mailing Address Fax Number:
772-562-5874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
530 21ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-5450
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-562-2020
Provider Business Practice Location Address Fax Number:
772-562-5874
Provider Enumeration Date:
09/08/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 156FX1800X , with the licence number:  DO3843 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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