Provider Demographics
NPI:1487044129
Name:ALBERT R DUCHARME
Entity Type:Organization
Organization Name:ALBERT R DUCHARME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LEAFERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-728-1700
Mailing Address - Street 1:1320 SHELFER ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-3929
Mailing Address - Country:US
Mailing Address - Phone:352-728-1700
Mailing Address - Fax:352-728-0057
Practice Address - Street 1:1320 SHELFER ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3929
Practice Address - Country:US
Practice Address - Phone:352-728-1700
Practice Address - Fax:352-728-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1146152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84052Medicare UPIN