1598068991 NPI number — PRESTON H. STARKS FAMILY EYECARE LLC

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 1598068991 NPI number — PRESTON H. STARKS FAMILY EYECARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRESTON H. STARKS FAMILY EYECARE LLC
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:
1598068991
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2641 LANTANA LAKES CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32246-4634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-564-4177
Provider Business Mailing Address Fax Number:
904-641-8072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12100 LEM TURNER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32218-2304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-564-4177
Provider Business Practice Location Address Fax Number:
904-641-8072
Provider Enumeration Date:
12/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
STARKS
Authorized Official First Name:
PRESTON
Authorized Official Middle Name:
HENRY
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
904-564-4177

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  OPC 2779 , 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)





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