Provider Demographics
NPI:1497805535
Name:TB EYE CARE PA
Entity Type:Organization
Organization Name:TB EYE CARE PA
Other - Org Name:INNOVISION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:N
Authorized Official - Last Name:GILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:727-489-0500
Mailing Address - Street 1:11650 131ST ST
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-4740
Mailing Address - Country:US
Mailing Address - Phone:727-489-0500
Mailing Address - Fax:727-489-0508
Practice Address - Street 1:1450 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5504
Practice Address - Country:US
Practice Address - Phone:727-381-3937
Practice Address - Fax:727-345-6956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIM507AMedicare PIN