Provider Demographics
NPI:1619245644
Name:SPACE COAST EYE CARE INC.
Entity Type:Organization
Organization Name:SPACE COAST EYE CARE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:321-723-9350
Mailing Address - Street 1:1051 PORT MALABAR BLVD NE STE 14
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-5153
Mailing Address - Country:US
Mailing Address - Phone:321-474-0491
Mailing Address - Fax:321-723-9397
Practice Address - Street 1:1051 PORT MALABAR BLVD NE STE 14
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-5153
Practice Address - Country:US
Practice Address - Phone:321-474-0491
Practice Address - Fax:321-723-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC4290152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty