Provider Demographics
NPI:1922052935
Name:PALM COAST EYEWEAR, LLC
Entity Type:Organization
Organization Name:PALM COAST EYEWEAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-794-2020
Mailing Address - Street 1:3131 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-5101
Mailing Address - Country:US
Mailing Address - Phone:941-954-1001
Mailing Address - Fax:941-951-6957
Practice Address - Street 1:3131 S TAMIAMI TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-5101
Practice Address - Country:US
Practice Address - Phone:941-954-1001
Practice Address - Fax:941-951-6957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO954332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDO1106OtherOPTICIAN LICENSE
FLDO1106OtherOPTICIAN LICENSE
=========OtherTAX IDENTIFICATION