MEDICARE: EYELID SURGERY CENTER, LLC

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	261QA1903X	Ambulatory Surgical Clinic/Center	1220	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6J5	OTHER	FL	BC/BS FLORIDA

General Provider Information

NPI Number	:	1255325080
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYELID SURGERY CENTER, LLC

Provider Business Mailing Address
First Line	:	15620 NEW HAMPSHIRE CT
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-4168
Country	:	US
Telephone Number	:	239-481-9995
Fax Number	:	239-481-9745

Provider Business Practice Location Address
First Line	:	15620 NEW HAMPSHIRE CT
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33908-4168
Country	:	US
Telephone Number	:	239-481-9995
Fax Number	:	239-481-9745

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. ROBERT DUANE MARTILLA
Credential	:	RN, LHRM
Telephone Number	:	239-481-9995

Provider Enumeration Date	:	09/08/2005
Last Update Date	:	08/22/2020

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