1174160972 NPI number — CASE VISION ASSOCIATES PA

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 1174160972 NPI number — CASE VISION ASSOCIATES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASE VISION ASSOCIATES 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:
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:
1174160972
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2564 ENTERPRISE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32763-7904
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-774-7242
Provider Business Mailing Address Fax Number:
386-774-8442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1474 W GRANADA BLVD STE 470
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-8240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-673-3011
Provider Business Practice Location Address Fax Number:
386-673-3099
Provider Enumeration Date:
11/30/2019

Additional Information

Authorized Official

Authorized Official Last Name:
CASE
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
386-673-3011

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)

  • Identifier: 106306000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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