Provider Demographics
NPI:1629128475
Name:E WINGO & P COLCHISKI PTR
Entity Type:Organization
Organization Name:E WINGO & P COLCHISKI PTR
Other - Org Name:EYECARE BOUTIQUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COOWNER-MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PENELOPE
Authorized Official - Middle Name:COLCHISKI
Authorized Official - Last Name:WINGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-629-2422
Mailing Address - Street 1:2437 E FORT KING ST
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-2558
Mailing Address - Country:US
Mailing Address - Phone:352-629-2422
Mailing Address - Fax:352-732-0177
Practice Address - Street 1:2437 E FORT KING ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-2558
Practice Address - Country:US
Practice Address - Phone:352-629-2422
Practice Address - Fax:352-732-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0028326332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL057222500Medicaid
SC1160000001Medicare NSC