=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356654008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL FLORIDA LOW VISION REHABILITATION RESOURCE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2010
-----------------------------------------------------
Last Update Date | 03/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 CENTRE CIR STE 2004
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-7242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-667-0007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 940 CENTRE CIR STE 2004
-----------------------------------------------------
City | ALTAMONTE SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-7242
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-667-0007
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. KENNETH LESLIE LIPSITT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 407-667-0007
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------