=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356105746
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE EYE ASSOCIATES OF MANATEE, LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2024
-----------------------------------------------------
Last Update Date | 07/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 811 RIDGEWOOD AVE
-----------------------------------------------------
City | VENICE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34285-7009
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-792-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 162264
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32716-2264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-792-2020
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | KEVIN BECKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 706-243-2259
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------