Healthcare Provider Details

I. General information

NPI: 1255055646
Provider Name (Legal Business Name): EDISON EYE CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19527 HIGHLAND OAKS DR STE 203
ESTERO FL
33928-9637
US

IV. Provider business mailing address

1214 SWEETWATER LN UNIT 2305
NAPLES FL
34110-4177
US

V. Phone/Fax

Practice location:
  • Phone: 616-834-2598
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN KONYNENBELT
Title or Position: MEMBER
Credential: OD
Phone: 616-834-2598