Provider Demographics
NPI:1598984676
Name:TOTAL VISION OF PORT ORANGE, INC.
Entity Type:Organization
Organization Name:TOTAL VISION OF PORT ORANGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:L
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:386-767-4449
Mailing Address - Street 1:5820 S WILLIAMSON BLVD STE 106
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-6400
Mailing Address - Country:US
Mailing Address - Phone:386-767-4449
Mailing Address - Fax:386-767-1980
Practice Address - Street 1:5820 S WILLIAMSON BLVD STE 106
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-6400
Practice Address - Country:US
Practice Address - Phone:386-767-4449
Practice Address - Fax:386-767-1980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620815100Medicaid
FL620815100Medicaid
FLK4711Medicare PIN