1730239815 NPI number — TB EYE CARE PA

Table of content: (NPI 1730239815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730239815 NPI number — TB EYE CARE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TB EYE CARE PA
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:
INNOVISION
Provider Other Organization Name Type Code:
3
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:
1730239815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11650 131ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LARGO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33774-4740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-489-0500
Provider Business Mailing Address Fax Number:
727-489-0508

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2643 GULF TO BAY BLVD STE 1520
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33759-4941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-799-3937
Provider Business Practice Location Address Fax Number:
727-210-1189
Provider Enumeration Date:
01/11/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GILLETTE
Authorized Official First Name:
THEODORE
Authorized Official Middle Name:
N
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
727-489-0500

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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