Basic Information
| Provider Information | |||||||||
| NPI: | 1730689530 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MICHAEL PENNACHIO, LLC | ||||||||
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| OtherOrganizationName: | MICHAEL PENNACHIO, LLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14244 SR 50 | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347118003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522271999 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 S GROVE ST | ||||||||
| Address2: | |||||||||
| City: | EUSTIS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327265524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522271999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2018 | ||||||||
| LastUpdateDate: | 02/19/2018 | ||||||||
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| AuthorizedOfficialLastName: | PENNACHIO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3522271999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MICHAEL PENNACHIO, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | ME45426 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.