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General NPI Number Information
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NPI Number | 1427098730
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Entity Type | Organization
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Legal Business Name | PALM COAST EYE CENTER, P.A.
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Dates
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Enumeration Date | 06/07/2006
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Last Update Date | 04/10/2008
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Provider Practice Location Address
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Address Line | 5601 21ST AVE W SUITE A
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City | BRADENTON
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State | FL
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Zip | 34209-5642
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Country | US
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Telephone | 941-794-2020
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Fax | 941-792-3464
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Provider Business Mailing Address
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Address Line | 5601 21ST AVE W SUITE A
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City | BRADENTON
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State | FL
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Zip | 34209-5642
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Country | US
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Telephone | 941-794-2020
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Fax | 941-792-3464
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | LISA RENEE NICHOLS
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Credential |
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Telephone | 941-794-2020
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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 | OPC3917
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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 | ME0045451
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License Number State | FL
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