Healthcare Provider Details

I. General information

NPI: 1194820571
Provider Name (Legal Business Name): EYE CENTER OF NORTH FLORIDA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 04/20/2023
Certification Date: 04/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MAIN ST
CHIPLEY FL
32428-6943
US

IV. Provider business mailing address

2500 MARTIN LUTHER KING JR BLVD
PANAMA CITY FL
32405-4412
US

V. Phone/Fax

Practice location:
  • Phone: 850-638-7333
  • Fax: 850-638-9727
Mailing address:
  • Phone: 850-522-7951
  • Fax: 850-522-9829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierCG6943
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerRR MEDICARE
# 2
Identifier1740213529
Identifier TypeOTHER
Identifier State
Identifier IssuerGROUP NPI NUMBER
# 3
Identifier257952902
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 4
Identifier45154B
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerBLUE CROSS & BLUE SHEILD
# 5
Identifier114961100
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name: MS. KATHI NICHOLS
Title or Position: OFFICE MANAGER
Credential:
Phone: 850-784-3937