Healthcare Provider Details

I. General information

NPI: 1770582835
Provider Name (Legal Business Name): COMMUNITY EYE OPTICAL LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21275 OLEAN BLVD
PORT CHARLOTTE FL
33952-6704
US

IV. Provider business mailing address

21275 OLEAN BLVD
PORT CHARLOTTE FL
33952-6704
US

V. Phone/Fax

Practice location:
  • Phone: 941-625-1960
  • Fax: 941-625-5780
Mailing address:
  • Phone: 941-625-1960
  • Fax: 941-625-5780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number79133
License Number StateFL

VIII. Authorized Official

Name: DR. ERIC R SCHAIBLE
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 941-625-1325