1508181165 NPI number — COMMUNITY EYE OPTICAL LC

Table of content: (NPI 1508181165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508181165 NPI number — COMMUNITY EYE OPTICAL LC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY EYE OPTICAL LC
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:
1508181165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2825 TAMIAMI TRL
Provider Second Line Business Mailing Address:
BLDG. B SUITE 3 & 4
Provider Business Mailing Address City Name:
PUNTA GORDA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33950-7269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
941-347-8346
Provider Business Mailing Address Fax Number:
941-347-8326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2825 TAMIAMI TRL
Provider Second Line Business Practice Location Address:
BLDG. B SUITE 3 & 4
Provider Business Practice Location Address City Name:
PUNTA GORDA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33950-7269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-347-8346
Provider Business Practice Location Address Fax Number:
941-347-8326
Provider Enumeration Date:
04/07/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BURNETTE
Authorized Official First Name:
HOLLY
Authorized Official Middle Name:
MCKAY
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
941-625-1325

Provider Taxonomy Codes

  • Taxonomy code: 332H00000X , with the licence number:  79133 , 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: 4769100005 . This is a "PTAN" identifier . This identifiers is of the category "OTHER".




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