Basic Information
| Provider Information | |||||||||
| NPI: | 1154842961 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERLMAN-HENSEN | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | |||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 MASON AVE SUITE 100 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862745525 | ||||||||
| FaxNumber: | 8032967330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 MASON AVE SUITE 100 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862745525 | ||||||||
| FaxNumber: | 8034341581 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2017 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2034 | SC | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 5214 | MA | N | Eye and Vision Services Providers | Optometrist | 152WC0802X | 5214 | MA | N | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management | 152W00000X | CPC5617 | FL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 110772100 | 05 | FL | MEDICAID | D20341 | 05 | SC | MEDICAID |