Provider Demographics
NPI:1093158404
Name:EYESTAT OPTOMETRIC SERVICES, P.A.
Entity Type:Organization
Organization Name:EYESTAT OPTOMETRIC SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:STATSICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-385-4738
Mailing Address - Street 1:720 PONDFIELD RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NC
Mailing Address - Zip Code:27569
Mailing Address - Country:US
Mailing Address - Phone:813-385-4738
Mailing Address - Fax:
Practice Address - Street 1:720 PONDFIELD RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:NC
Practice Address - Zip Code:27569
Practice Address - Country:US
Practice Address - Phone:813-385-4738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-16
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1407162043OtherNPI