Provider Demographics
NPI:1760636187
Name:ALLIGATOR ISLAND OPTICAL
Entity Type:Organization
Organization Name:ALLIGATOR ISLAND OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER, OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:VIRGIL
Authorized Official - Last Name:KNOWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:352-332-9028
Mailing Address - Street 1:2725 SW 91ST ST
Mailing Address - Street 2:SUITE 160
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-2781
Mailing Address - Country:US
Mailing Address - Phone:352-332-9028
Mailing Address - Fax:352-332-9030
Practice Address - Street 1:2725 SW 91ST ST
Practice Address - Street 2:SUITE 160
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-2781
Practice Address - Country:US
Practice Address - Phone:352-332-9028
Practice Address - Fax:352-332-9030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-12
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO 5908332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6173320001Medicare NSC