Provider Demographics
NPI:1639217540
Name:PROVISION LASER EYE CENTER PA
Entity Type:Organization
Organization Name:PROVISION LASER EYE CENTER PA
Other - Org Name:PROVISION EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:P
Authorized Official - Last Name:DURRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-493-0311
Mailing Address - Street 1:1191 JACARANDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-4518
Mailing Address - Country:US
Mailing Address - Phone:941-493-0311
Mailing Address - Fax:941-492-4655
Practice Address - Street 1:473 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-3736
Practice Address - Country:US
Practice Address - Phone:941-475-8532
Practice Address - Fax:941-460-0642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5255640002Medicare NSC