Provider Demographics
NPI:1922403005
Name:COLLEGE EYECARE LLC
Entity Type:Organization
Organization Name:COLLEGE EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:352-409-5783
Mailing Address - Street 1:2984 ALAFAYA TRL
Mailing Address - Street 2:# 1030
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-7628
Mailing Address - Country:US
Mailing Address - Phone:352-409-5783
Mailing Address - Fax:
Practice Address - Street 1:11099 SW 10TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33199-0001
Practice Address - Country:US
Practice Address - Phone:305-348-8439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 1726152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty