Basic Information
| Provider Information | |||||||||
| NPI: | 1477745552 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED CARE EYE CENTER LIMITED LIABILITY COMPANY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVANCED EYECARE INSTITUTE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 S BUNGALOW PARK AVE | ||||||||
| Address2: | UNIT B | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336093159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138782020 | ||||||||
| FaxNumber: | 8133855008 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 S PARSONS AVE | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138762020 | ||||||||
| FaxNumber: | 8133855008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2007 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RATHINASAMY | ||||||||
| AuthorizedOfficialFirstName: | DILIP | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8138782020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME98257 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 000121500 | 05 | FL | MEDICAID |