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General NPI Number Information
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NPI Number | 1831822899
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Entity Type | Organization
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Legal Business Name | COASTAL CLEAR EYECARE
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Dates
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Enumeration Date | 07/07/2022
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Last Update Date | 07/07/2022
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Provider Practice Location Address
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Address Line | 155 FOUNTAINS WAY UNIT 11
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City | SAINT JOHNS
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State | FL
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Zip | 32259-1143
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Country | US
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Telephone | 404-932-2802
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Fax |
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Provider Business Mailing Address
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Address Line | 133 RUM RUNNER WAY
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City | SAINT JOHNS
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State | FL
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Zip | 32259-2267
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Country | US
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Telephone | 404-932-2802
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DR. ROMANDA DEMETRIOS
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Credential | OD
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Telephone | 404-932-2802
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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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