MEDICARE: BLAHNIK EYE CARE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPC2215	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043462914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLAHNIK EYE CARE INC

Provider Business Mailing Address
First Line	:	3740 S RIDGEWOOD AVE
Second Line	:	UNIT 103
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3510
Country	:	US
Telephone Number	:	386-492-6999
Fax Number	:	386-492-6900

Provider Business Practice Location Address
First Line	:	3740 S RIDGEWOOD AVE
Second Line	:	UNIT 103
City	:	PORT ORANGE
State	:	FL
Zip	:	32129-3510
Country	:	US
Telephone Number	:	386-492-6999
Fax Number	:	386-492-6900

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SUZETTE A BLAHNIK
Credential	:	O.D.
Telephone Number	:	386-492-6999

Provider Enumeration Date	:	10/22/2008
Last Update Date	:	03/05/2010

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