1376553925 NPI number — CAPE CORAL EYE CENTER, P.A.

Table of content: (NPI 1376553925)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376553925 NPI number — CAPE CORAL EYE CENTER, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPE CORAL 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:
EYE SURGERY & LASER CENTER, P.A.
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:
1376553925
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 101427
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAPE CORAL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-540-8718
Provider Business Mailing Address Fax Number:
239-945-0847

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4120 DEL PRADO BLVD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAPE CORAL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33904-7165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-542-2020
Provider Business Practice Location Address Fax Number:
239-541-1492
Provider Enumeration Date:
08/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TYSON
Authorized Official First Name:
FARRELL
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
239-542-2020

Provider Taxonomy Codes

  • Taxonomy code: 261QS0132X , with the licence number:  808 , 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: 079051600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 61Z . This is a "BC/BS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: N221470 . This is a "STAYWELL MEDICAID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2242484 . This is a "AETNA HMO" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 490001086 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 079051600 . 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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