Healthcare Provider Details

I. General information

NPI: 1881047850
Provider Name (Legal Business Name): LOW VISION OF PANAMA CITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2016
Last Update Date: 07/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 HARRISON AVE
PANAMA CITY FL
32401-2526
US

IV. Provider business mailing address

826 HARRISON AVE
PANAMA CITY FL
32401-2526
US

V. Phone/Fax

Practice location:
  • Phone: 850-769-1404
  • Fax: 850-769-0748
Mailing address:
  • Phone: 850-769-1404
  • Fax: 850-769-0748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5212
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code152WL0500X
TaxonomyLow Vision Rehabilitation Optometrist
License NumberOPC5212
License Number StateFL

VIII. Authorized Official

Name: STEPHANIE QUESADA MOORE
Title or Position: OWNER
Credential: OD
Phone: 850-769-1404