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General NPI Number Information
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NPI Number | 1912053547
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Entity Type | Organization
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Legal Business Name | ST JOHNS EYE CARE P A
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 07/09/2024
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Provider Practice Location Address
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Address Line | 2504 CRILL AVE
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City | PALATKA
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State | FL
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Zip | 32177-4264
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Country | US
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Telephone | 386-328-5141
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Fax | 386-328-3972
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Provider Business Mailing Address
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Address Line | 2504 CRILL AVE
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City | PALATKA
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State | FL
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Zip | 32177-4264
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Country | US
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Telephone | 386-328-5141
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Fax | 386-328-3972
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN M LENNON
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Credential | O.D
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Telephone | 386-328-5141
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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 | 20061021
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License Number State | FL
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