Provider Demographics
NPI:1003955568
Name:COUZENS STAM DOMINGO PA
Entity Type:Organization
Organization Name:COUZENS STAM DOMINGO PA
Other - Org Name:BEACHES FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:STAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-246-4831
Mailing Address - Street 1:905 BEACH BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-4303
Mailing Address - Country:US
Mailing Address - Phone:904-246-4831
Mailing Address - Fax:904-249-5876
Practice Address - Street 1:905 BEACH BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-4303
Practice Address - Country:US
Practice Address - Phone:904-246-4831
Practice Address - Fax:904-249-5876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3453152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty