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General NPI Number Information
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NPI Number | 1255325080
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Entity Type | Organization
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Legal Business Name | EYELID SURGERY CENTER, LLC
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Dates
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Enumeration Date | 09/08/2005
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 15620 NEW HAMPSHIRE CT
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City | FORT MYERS
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State | FL
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Zip | 33908-4168
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Country | US
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Telephone | 239-481-9995
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Fax | 239-481-9745
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Provider Business Mailing Address
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Address Line | 15620 NEW HAMPSHIRE CT
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City | FORT MYERS
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State | FL
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Zip | 33908-4168
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Country | US
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Telephone | 239-481-9995
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Fax | 239-481-9745
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. ROBERT DUANE MARTILLA
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Credential | RN, LHRM
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Telephone | 239-481-9995
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 1220
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License Number State | FL
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