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General NPI Number Information
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NPI Number | 1285670117
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Entity Type | Organization
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Legal Business Name | ADVANCED SURGICAL AND MEDICAL EYE CARE P A
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Dates
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Enumeration Date | 06/20/2006
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Last Update Date | 08/18/2010
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Provider Practice Location Address
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Address Line | 936 BICHARA BLVD
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City | LADY LAKE
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State | FL
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Zip | 32159-7714
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Country | US
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Telephone | 352-753-9888
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Fax | 352-753-0947
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Provider Business Mailing Address
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Address Line | 936 BICHARA BLVD
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City | LADY LAKE
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State | FL
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Zip | 32159-7714
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Country | US
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Telephone | 352-753-9888
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Fax | 352-753-0947
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. TRACY MICHELLE MASTERS
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Credential | CO, COMT
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Telephone | 352-753-9888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | OPC2612
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | ME89546
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | ME0071525
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License Number State | FL
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