MEDICARE: TB EYE CARE PA

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

General Provider Information

NPI Number	:	1497805535
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TB EYE CARE PA

Provider Business Mailing Address
First Line	:	11650 131ST ST
Second Line	:
City	:	LARGO
State	:	FL
Zip	:	33774-4740
Country	:	US
Telephone Number	:	727-489-0500
Fax Number	:	727-489-0508

Provider Business Practice Location Address
First Line	:	1450 66TH ST N
Second Line	:
City	:	ST PETERSBURG
State	:	FL
Zip	:	33710-5504
Country	:	US
Telephone Number	:	727-381-3937
Fax Number	:	727-345-6956

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. THEODORE N GILLETTE
Credential	:	O.D.
Telephone Number	:	727-489-0500

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	05/17/2016

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