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General NPI Number Information
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NPI Number | 1922052935
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Entity Type | Organization
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Legal Business Name | PALM COAST EYEWEAR, LLC
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Dates
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Enumeration Date | 05/22/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 3131 S TAMIAMI TRL SUITE 101
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City | SARASOTA
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State | FL
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Zip | 34239-5101
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Country | US
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Telephone | 941-954-1001
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Fax | 941-951-6957
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Provider Business Mailing Address
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Address Line | 3131 S TAMIAMI TRL SUITE 101
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City | SARASOTA
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State | FL
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Zip | 34239-5101
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Country | US
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Telephone | 941-954-1001
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Fax | 941-951-6957
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | LISA RENEE NICHOLS
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Credential |
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Telephone | 941-794-2020
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | DO954
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License Number State | FL
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