Healthcare Provider Details

I. General information

NPI: 1619119948
Provider Name (Legal Business Name): CRYSTAL RIVER EYE CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 05/23/2023
Certification Date: 05/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 SE US HIGHWAY 19
CRYSTAL RIVER FL
34429-4880
US

IV. Provider business mailing address

PO BOX 3979
SARASOTA FL
34230-3979
US

V. Phone/Fax

Practice location:
  • Phone: 216-338-7773
  • Fax: 352-563-2598
Mailing address:
  • Phone: 523-795-6622
  • Fax: 352-563-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME061395
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License NumberME61395
License Number StateFL

VIII. Authorized Official

Name: REGINA I WEBB
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 352-795-6622