=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871901934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY EYE CARE OF PALM COAST, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2014
-----------------------------------------------------
Last Update Date | 08/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 OFFICE PARK DR SUITE 4
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-3855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-225-4553
-----------------------------------------------------
Fax | 386-225-4558
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 OFFICE PARK DR SUITE 4
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-3855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-225-4553
-----------------------------------------------------
Fax | 386-225-4558
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BONNIE M CHALKER
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 386-225-4553
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | OPC 3585
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------