Provider Demographics
NPI:1306387261
Name:FAMILY EYECARE OF WINTER HAVEN PLLC
Entity Type:Organization
Organization Name:FAMILY EYECARE OF WINTER HAVEN PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENNE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:863-293-0276
Mailing Address - Street 1:410 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-3050
Mailing Address - Country:US
Mailing Address - Phone:863-293-0276
Mailing Address - Fax:863-299-3172
Practice Address - Street 1:410 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3050
Practice Address - Country:US
Practice Address - Phone:863-293-0276
Practice Address - Fax:863-299-3172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-12
Last Update Date:2017-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU1636VMedicare PIN
FL19298Medicare PIN