Provider Demographics
NPI:1891787446
Name:MELBOURNE UNITED LASER VISION ASSOCIATION LLC
Entity Type:Organization
Organization Name:MELBOURNE UNITED LASER VISION ASSOCIATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:TEATHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-242-2026
Mailing Address - Street 1:1478 HIGHLAND AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6561
Mailing Address - Country:US
Mailing Address - Phone:321-242-2026
Mailing Address - Fax:321-242-2423
Practice Address - Street 1:1478 HIGHLAND AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-6561
Practice Address - Country:US
Practice Address - Phone:321-242-2026
Practice Address - Fax:321-242-2423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-19
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66195207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375920200Medicaid
FL375920200Medicaid
25575Medicare PIN