Basic Information
| Provider Information | |||||||||
| NPI: | 1427098730 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PALM COAST EYE CENTER, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5601 21ST AVE W | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417942020 | ||||||||
| FaxNumber: | 9417923464 | ||||||||
| Practice Location | |||||||||
| Address1: | 5601 21ST AVE W | ||||||||
| Address2: | SUITE A | ||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342095642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417942020 | ||||||||
| FaxNumber: | 9417923464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 04/10/2008 | ||||||||
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| AuthorizedOfficialLastName: | NICHOLS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | RENEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9417942020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPC3917 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 207W00000X | ME0045451 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | CJ5917 | 01 | FL | RAILROAD MEDICARE GROUP | OTHER |