Provider Demographics
NPI:1053365056
Name:PALM COAST EYE CENTER, P.A.
Entity type:Organization
Organization Name:PALM COAST EYE CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-794-2020
Mailing Address - Street 1:5601 21ST AVE W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5642
Mailing Address - Country:US
Mailing Address - Phone:941-794-2020
Mailing Address - Fax:941-792-3464
Practice Address - Street 1:3131 S TAMIAMI TRL
Practice Address - Street 2:SUITE 201
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5101
Practice Address - Country:US
Practice Address - Phone:941-954-2020
Practice Address - Fax:941-953-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3917152W00000X
FLME0045451207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCJ5917OtherRAILROAD MEDICARE GROUP
FLD58970Medicare UPIN
FLK0672Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
FLCJ5917OtherRAILROAD MEDICARE GROUP
FLU3993YMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
FL79896ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER