=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891747176
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TOMOKA EYE ASSOCIATES, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2006
-----------------------------------------------------
Last Update Date | 03/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 790 DUNLAWTON AVE SUITE A
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-767-0053
-----------------------------------------------------
Fax | 386-767-3490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 790 DUNLAWTON AVE SUITE A
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32127-4222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-767-0053
-----------------------------------------------------
Fax | 386-767-3490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE/BILLING MANAGER
-----------------------------------------------------
Name | ALLISON KERN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-506-8403
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------