Provider Demographics
NPI:1790015303
Name:EYE WORKS OF LAND O' LAKES
Entity Type:Organization
Organization Name:EYE WORKS OF LAND O' LAKES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEE
Authorized Official - Middle Name:ME
Authorized Official - Last Name:KANICKY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-949-1982
Mailing Address - Street 1:3249 STONEGATE FALLS DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-6195
Mailing Address - Country:US
Mailing Address - Phone:813-495-8883
Mailing Address - Fax:813-948-0351
Practice Address - Street 1:21517 VILLAGE LAKES SHOPPING CTR DR
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-5101
Practice Address - Country:US
Practice Address - Phone:813-949-1982
Practice Address - Fax:813-948-0351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-04
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001159152W00000X
FLOPC003906152W00000X
FLOPC003907152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621017100Medicaid
FL621016300Medicaid
FL084928600Medicaid
FL621017100Medicaid
FLCU581AMedicare PIN