Basic Information
| Provider Information | |||||||||
| NPI: | 1992770176 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA EYE CLINIC P A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 160 BOSTON AVE | ||||||||
| Address2: | |||||||||
| City: | ALTAMONTE SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327014706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073390303 | ||||||||
| FaxNumber: | 4073390961 | ||||||||
| Practice Location | |||||||||
| Address1: | 5727 CANTON CV | ||||||||
| Address2: | #111 | ||||||||
| City: | WINTER SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327085033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076952020 | ||||||||
| FaxNumber: | 4076995666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 11/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | PAPPAS | ||||||||
| AuthorizedOfficialFirstName: | HARRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4078347776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FLORIDA EYE CLINIC P A | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 152W00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 208488107 | 05 | FL | MEDICAID |