Basic Information
| Provider Information | |||||||||
| NPI: | 1063701977 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEW VISION SURGICAL CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 37TH PL | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329606551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578700 | ||||||||
| FaxNumber: | 7722578715 | ||||||||
| Practice Location | |||||||||
| Address1: | 1055 37TH PL | ||||||||
| Address2: | |||||||||
| City: | VERO BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329606551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7722578700 | ||||||||
| FaxNumber: | 7722578715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2011 | ||||||||
| LastUpdateDate: | 10/03/2011 | ||||||||
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| AuthorizedOfficialLastName: | MINOTTY | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | VICTOR | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7722578700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1345 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 10C0001563 | 01 | FL | MEDICARE ASC IDENTIFICATION NUMBER | OTHER |