Healthcare Provider Details

I. General information

NPI: 1982915922
Provider Name (Legal Business Name): EYE SITE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9433 BALM RIVERVIEW RD STE 102
RIVERVIEW FL
33569-5120
US

IV. Provider business mailing address

9433 BALM RIVERVIEW RD STE 102
RIVERVIEW FL
33569-5120
US

V. Phone/Fax

Practice location:
  • Phone: 813-677-2995
  • Fax: 813-677-5549
Mailing address:
  • Phone: 813-677-2995
  • Fax: 813-677-5549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberOPC2762
License Number StateFL

VIII. Authorized Official

Name: MR. MARK S. LUEDKE
Title or Position: PRES
Credential:
Phone: 813-677-2995