Provider Demographics
NPI:1477120723
Name:EVANS TELEOPTOMETRIC SERVICE FL PA
Entity Type:Organization
Organization Name:EVANS TELEOPTOMETRIC SERVICE FL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF OPEN DOCTOR PANEL
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASILE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-243-8708
Mailing Address - Street 1:1270 SAXON BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8418
Mailing Address - Country:US
Mailing Address - Phone:863-774-5000
Mailing Address - Fax:
Practice Address - Street 1:1270 SAXON BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8418
Practice Address - Country:US
Practice Address - Phone:386-774-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-07
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty