Healthcare Provider Details

I. General information

NPI: 1932372158
Provider Name (Legal Business Name): FULL SPECTRUM FAMILY VISION CARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 05/26/2020
Certification Date: 05/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 DEL PRADO BLVD S STE 101
CAPE CORAL FL
33990-1743
US

IV. Provider business mailing address

217 DEL PRADO BLVD S STE 101
CAPE CORAL FL
33990-1743
US

V. Phone/Fax

Practice location:
  • Phone: 239-573-3937
  • Fax: 239-573-0263
Mailing address:
  • Phone: 239-573-3937
  • Fax: 239-573-0263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC3636
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberOPC3636
License Number StateFL

VIII. Authorized Official

Name: DR. HEATHER L TRAPHEAGEN
Title or Position: OWNER/PRESIDENT
Credential: OD
Phone: 239-573-3937