Healthcare Provider Details

I. General information

NPI: 1720380389
Provider Name (Legal Business Name): EYE SITE VISION CENTER II, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 02/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2490 N FEDERAL HWY
LIGHTHOUSE POINT FL
33064-6812
US

IV. Provider business mailing address

2490 N FEDERAL HWY
LIGHTHOUSE POINT FL
33064-6812
US

V. Phone/Fax

Practice location:
  • Phone: 954-943-3779
  • Fax: 954-943-3879
Mailing address:
  • Phone: 954-943-3779
  • Fax: 954-943-3879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License NumberOPC2575
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License NumberOPC2575
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License NumberOPC2575
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC2575
License Number StateFL

VIII. Authorized Official

Name: DR. GARY E GOBERVILLE
Title or Position: PRES/OPTOMETRIST
Credential: OD
Phone: 954-943-3779