Provider Demographics
NPI:1417006073
Name:TAYLOR CREEK OPTICAL INC
Entity Type:Organization
Organization Name:TAYLOR CREEK OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:PALMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-468-0008
Mailing Address - Street 1:104 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4403
Mailing Address - Country:US
Mailing Address - Phone:772-468-0008
Mailing Address - Fax:772-468-6628
Practice Address - Street 1:104 N 2ND ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950
Practice Address - Country:US
Practice Address - Phone:772-468-0008
Practice Address - Fax:772-468-6628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO3798156FX1800X
FLOE480332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD7706OtherBCBS
0855120001OtherDME SUPPLIER
FLFL3798OtherEYE MED