Provider Demographics
NPI:1609104637
Name:JAX VISION CARE, PA
Entity Type:Organization
Organization Name:JAX VISION CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-472-0084
Mailing Address - Street 1:201 N HOGAN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32202-4203
Mailing Address - Country:US
Mailing Address - Phone:904-356-9431
Mailing Address - Fax:904-356-2969
Practice Address - Street 1:201 N HOGAN ST STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-4203
Practice Address - Country:US
Practice Address - Phone:904-356-9431
Practice Address - Fax:904-356-2969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-02
Last Update Date:2022-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3718152W00000X
FLOPC4005152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002039300Medicaid
FLDQ2057Medicare PIN
FLCY058AMedicare PIN