1972707958 NPI number — TOTAL VISION OF PALM COAST INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972707958 NPI number — TOTAL VISION OF PALM COAST INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOTAL VISION OF PALM COAST INC
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:
TOTAL VISION EYE HEALTH ASSOC.
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:
1972707958
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/24/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 CYPRESS BRANCH WAY
Provider Second Line Business Mailing Address:
SUITE #205
Provider Business Mailing Address City Name:
PALM COAST
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32164-8413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-445-1880
Provider Business Mailing Address Fax Number:
386-445-8796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 CYPRESS BRANCH WAY
Provider Second Line Business Practice Location Address:
SUITE #205
Provider Business Practice Location Address City Name:
PALM COAST
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32164-8413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-445-1880
Provider Business Practice Location Address Fax Number:
386-445-8796
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHENS
Authorized Official First Name:
PHILLIP
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-445-1880

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC 0002395 , 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: 078287400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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