=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790721652
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MILLENNIUM EYE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2006
-----------------------------------------------------
Last Update Date | 06/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 OLD WINTER GARDEN RD SUIT 104
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-292-9812
-----------------------------------------------------
Fax | 407-292-9813
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6601 OLD WINTER GARDEN RD SUIT 104
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-292-9812
-----------------------------------------------------
Fax | 407-292-9813
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARIE LAURETTA SEIDE-JUSTIN
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 407-292-9812
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPC003955
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------