Provider Demographics
NPI:1629392261
Name:CAPE CORAL EYE CENTER, P.A.
Entity Type:Organization
Organization Name:CAPE CORAL EYE CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLO
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:239-542-2020
Mailing Address - Street 1:P.O. BOX 101427
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33910
Mailing Address - Country:US
Mailing Address - Phone:239-540-8718
Mailing Address - Fax:239-945-0847
Practice Address - Street 1:4085 HANCOCK BRIDGE PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:N FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-7219
Practice Address - Country:US
Practice Address - Phone:239-542-2020
Practice Address - Fax:239-567-5248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620840100Medicaid
FL28686ZMedicare PIN
FL620840100Medicaid