Provider Demographics
NPI:1790721652
Name:MILLENNIUM EYE CENTER, INC.
Entity Type:Organization
Organization Name:MILLENNIUM EYE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:LAURETTA
Authorized Official - Last Name:SEIDE-JUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:407-292-9812
Mailing Address - Street 1:6601 OLD WINTER GARDEN RD
Mailing Address - Street 2:SUIT 104
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-1221
Mailing Address - Country:US
Mailing Address - Phone:407-292-9812
Mailing Address - Fax:407-292-9813
Practice Address - Street 1:6601 OLD WINTER GARDEN RD
Practice Address - Street 2:SUIT 104
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-1221
Practice Address - Country:US
Practice Address - Phone:407-292-9812
Practice Address - Fax:407-292-9813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC003955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621147000Medicaid
FL621147000Medicaid
FLAB736Medicare PIN