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General NPI Number Information
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NPI Number | 1982915922
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Entity Type | Organization
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Legal Business Name | EYE SITE CENTER, INC.
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Dates
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Enumeration Date | 06/24/2010
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Last Update Date | 09/22/2011
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Provider Practice Location Address
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Address Line | 9433 BALM RIVERVIEW RD STE 102
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City | RIVERVIEW
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State | FL
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Zip | 33569-5120
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Country | US
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Telephone | 813-677-2995
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Fax | 813-677-5549
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Provider Business Mailing Address
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Address Line | 9433 BALM RIVERVIEW RD STE 102
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City | RIVERVIEW
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State | FL
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Zip | 33569-5120
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Country | US
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Telephone | 813-677-2995
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Fax | 813-677-5549
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Authorized Official
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Title or Position | PRES
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Name | MR. MARK S. LUEDKE
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Credential |
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Telephone | 813-677-2995
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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 | OPC2762
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License Number State | FL
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