Provider Demographics
NPI:1093035032
Name:ST. CLOUD EYE CARE
Entity Type:Organization
Organization Name:ST. CLOUD EYE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-556-3969
Mailing Address - Street 1:2050 OLD HICKORY TREE RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8926
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2050 OLD HICKORY TREE RD
Practice Address - Street 2:SUITE I
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34772-8926
Practice Address - Country:US
Practice Address - Phone:407-556-3969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4211152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621268900Medicaid