Healthcare Provider Details

I. General information

NPI: 1013027317
Provider Name (Legal Business Name): VISUAL HEALTH AT JUPITER EYE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 COASTAL WAY #103
JUPITER FL
33477-5004
US

IV. Provider business mailing address

2889 10TH AVE N STE 305
LAKE WORTH FL
33461-3045
US

V. Phone/Fax

Practice location:
  • Phone: 561-747-1111
  • Fax: 561-744-6682
Mailing address:
  • Phone: 561-964-0707
  • Fax: 561-227-3183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MADONNA COFFMAN
Title or Position: ADMINISTARTOR
Credential:
Phone: 561-227-3101