Provider Demographics
NPI:1508181165
Name:COMMUNITY EYE OPTICAL LC
Entity Type:Organization
Organization Name:COMMUNITY EYE OPTICAL LC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:MCKAY
Authorized Official - Last Name:BURNETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-625-1325
Mailing Address - Street 1:2825 TAMIAMI TRL
Mailing Address - Street 2:BLDG. B SUITE 3 & 4
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-7269
Mailing Address - Country:US
Mailing Address - Phone:941-347-8346
Mailing Address - Fax:941-347-8326
Practice Address - Street 1:2825 TAMIAMI TRL
Practice Address - Street 2:BLDG. B SUITE 3 & 4
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-7269
Practice Address - Country:US
Practice Address - Phone:941-347-8346
Practice Address - Fax:941-347-8326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-07
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL79133332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4769100005OtherPTAN