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General NPI Number Information
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NPI Number | 1669036430
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Entity Type | Organization
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Legal Business Name | CYPRESS LAKE EYE CARE LLC
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Dates
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Enumeration Date | 04/27/2019
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Last Update Date | 04/27/2019
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Provider Practice Location Address
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Address Line | 7171 CYPRESS LAKE DR
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City | FORT MYERS
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State | FL
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Zip | 33907-6521
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Country | US
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Telephone | 239-415-3806
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Fax |
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Provider Business Mailing Address
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Address Line | 7688 CYPRESS WALK DR
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City | FORT MYERS
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State | FL
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Zip | 33966-5805
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Country | US
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Telephone | 616-610-1685
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Fax |
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Authorized Official
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Title or Position | OPTOMETRIST
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Name | ANDREW JOHN VANEENENAAM
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Credential | OD
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Telephone | 616-610-1685
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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 |
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License Number State |
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