Healthcare Provider Details

I. General information

NPI: 1073764106
Provider Name (Legal Business Name): FLORIDA EYE CLINIC AMBULATORY SURGICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 10/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 TOWN CENTER DR SUITE 100
ORANGE CITY FL
32763-8269
US

IV. Provider business mailing address

160 BOSTON AVE
ALTAMONTE SPRINGS FL
32701-4706
US

V. Phone/Fax

Practice location:
  • Phone: 407-834-7776
  • Fax: 407-834-0973
Mailing address:
  • Phone: 407-834-7776
  • Fax: 407-834-0973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number945
License Number StateFL

VIII. Authorized Official

Name: GEN PARM
Title or Position: ADMINISTRATOR
Credential:
Phone: 407-834-7776