=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477692135
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY EYE CARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2007
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 PAGE BACON RD SUITE 13
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-243-7100
-----------------------------------------------------
Fax | 850-243-6555
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 PAGE BACON RD SUITE 13
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-243-7100
-----------------------------------------------------
Fax | 850-243-6555
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSEPH M BAZARTE
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 850-243-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC001596
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------