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General NPI Number Information
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NPI Number | 1144699042
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Entity Type | Organization
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Legal Business Name | FORT PIERCE VISION LLC
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Dates
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Enumeration Date | 09/21/2015
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Last Update Date | 09/21/2015
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Provider Practice Location Address
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Address Line | 5100 OKEECHOBEE RD
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City | FORT PIERCE
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State | FL
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Zip | 34947-5428
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Country | US
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Telephone | 954-821-1111
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Fax | 772-336-9017
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Provider Business Mailing Address
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Address Line | 5100 OKEECHOBEE RD
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City | FORT PIERCE
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State | FL
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Zip | 34947-5428
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Country | US
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Telephone | 954-821-1111
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Fax | 772-336-9017
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Authorized Official
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Title or Position | MANAGER
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Name | DR. PHILIP C DESANTIS
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Credential | O.D.
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Telephone | 954-821-1111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | OPC2169
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License Number State | FL
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