Provider Demographics
NPI:1669036430
Name:CYPRESS LAKE EYE CARE LLC
Entity Type:Organization
Organization Name:CYPRESS LAKE EYE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:VANEENENAAM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-610-1685
Mailing Address - Street 1:7688 CYPRESS WALK DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-5805
Mailing Address - Country:US
Mailing Address - Phone:616-610-1685
Mailing Address - Fax:
Practice Address - Street 1:7171 CYPRESS LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-6521
Practice Address - Country:US
Practice Address - Phone:239-415-3806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-27
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty