Provider Demographics
NPI:1255325080
Name:EYELID SURGERY CENTER, LLC
Entity Type:Organization
Organization Name:EYELID SURGERY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:MARTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:RN, LHRM
Authorized Official - Phone:239-481-9995
Mailing Address - Street 1:15620 NEW HAMPSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4168
Mailing Address - Country:US
Mailing Address - Phone:239-481-9995
Mailing Address - Fax:239-481-9745
Practice Address - Street 1:15620 NEW HAMPSHIRE CT
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4168
Practice Address - Country:US
Practice Address - Phone:239-481-9995
Practice Address - Fax:239-481-9745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1220261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6J5OtherBC/BS FLORIDA
FL6J5OtherBC/BS FLORIDA