=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275778920
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE NONA EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2008
-----------------------------------------------------
Last Update Date | 06/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10743 NARCOOSSEE RD A-25
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-6944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-9990
-----------------------------------------------------
Fax | 407-658-8880
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10743 NARCOOSSEE RD A-25
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32832-6944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-658-9990
-----------------------------------------------------
Fax | 407-658-8880
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. CYNTHIA WARD
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 407-658-9990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | OPC 4075
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------