Provider Demographics
NPI:1275068595
Name:PERFORMANCE EYECARE, PA
Entity Type:Organization
Organization Name:PERFORMANCE EYECARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:JON
Authorized Official - Last Name:BAUSBACK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-877-8635
Mailing Address - Street 1:2827 BON AIR AVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34234-7345
Mailing Address - Country:US
Mailing Address - Phone:941-361-9491
Mailing Address - Fax:904-512-6636
Practice Address - Street 1:2827 BON AIR AVE
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34234-7345
Practice Address - Country:US
Practice Address - Phone:941-361-9491
Practice Address - Fax:904-512-6636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-24
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5052152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INU52381Medicare UPIN
INM400049398Medicare PIN