1427098730 NPI number — PALM COAST EYE CENTER, P.A.

Table of content: (NPI 1427098730)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427098730 NPI number — PALM COAST EYE CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PALM COAST EYE CENTER, P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1427098730
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5601 21ST AVE W
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
BRADENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34209-5642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-794-2020
Provider Business Mailing Address Fax Number:
941-792-3464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5601 21ST AVE W
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
BRADENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34209-5642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-794-2020
Provider Business Practice Location Address Fax Number:
941-792-3464
Provider Enumeration Date:
06/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
LISA
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
941-794-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC3917 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: ME0045451 , 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)

  • Identifier: CJ5917 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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