Provider Demographics
NPI:1689845471
Name:EASTGATE VISION CENTER
Entity Type:Organization
Organization Name:EASTGATE VISION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:386-328-2008
Mailing Address - Street 1:164 HWY 17 SOUTH
Mailing Address - Street 2:SUITE 12-C
Mailing Address - City:EAST PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32131
Mailing Address - Country:US
Mailing Address - Phone:386-328-2008
Mailing Address - Fax:386-328-2008
Practice Address - Street 1:164 HWY 17 SOUTH
Practice Address - Street 2:SUITE 12-C EASTGATE VISION CENTER
Practice Address - City:EAST PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32131
Practice Address - Country:US
Practice Address - Phone:386-328-2008
Practice Address - Fax:386-328-2008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD01128156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1079270001Medicare NSC
6381880001Medicare NSC