=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215348123
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE CARE OF SOUTH WEST FLORIDA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/13/2014
-----------------------------------------------------
Last Update Date | 06/26/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2382 IMMOKALEE RD
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34110-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-631-6451
-----------------------------------------------------
Fax | 239-631-6455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2382 IMMOKALEE RD
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34110-1446
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-631-6451
-----------------------------------------------------
Fax | 239-631-6455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. JILL SAGONA
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 239-631-6451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC3905
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------