1235778978 NPI number — SUNCOAST EYECARE CENTERS PLLC

Table of content: (NPI 1235778978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235778978 NPI number — SUNCOAST EYECARE CENTERS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUNCOAST EYECARE CENTERS PLLC
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:
6
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:
1235778978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13553 STATE ROAD 54 # 303
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ODESSA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33556-3527
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-540-7585
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2416 W BRANDON BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANDON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33511-4717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-684-7071
Provider Business Practice Location Address Fax Number:
813-324-7580
Provider Enumeration Date:
12/28/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BUTCHER
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
405-923-4147

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: 108621500 . 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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