Provider Demographics
NPI:1114962677
Name:BEACON VISION CENTER, INC
Entity Type:Organization
Organization Name:BEACON VISION CENTER, INC
Other - Org Name:BEACON ADVANCED EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CORP SEC
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J
Authorized Official - Last Name:NAUMANN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:352-728-8318
Mailing Address - Street 1:1320 SHELFER ST
Mailing Address - Street 2:BEACON ADVANCED EYE CARE
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3929
Mailing Address - Country:US
Mailing Address - Phone:352-728-8318
Mailing Address - Fax:352-728-0057
Practice Address - Street 1:1320 SHELFER ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3929
Practice Address - Country:US
Practice Address - Phone:352-728-8318
Practice Address - Fax:352-728-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332H00000X
FL1146335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL630288200Medicaid
FL0710910001Medicare ID - Type Unspecified