Provider Demographics
NPI:1942484654
Name:EARTH VISION EYE CARE INC
Entity Type:Organization
Organization Name:EARTH VISION EYE CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:W
Authorized Official - Last Name:PITTALUGA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:561-988-0300
Mailing Address - Street 1:5499 N FEDERAL HWY STE E
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-4993
Mailing Address - Country:US
Mailing Address - Phone:561-988-0300
Mailing Address - Fax:561-988-0350
Practice Address - Street 1:5499 N FEDERAL HWY STE E
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-4993
Practice Address - Country:US
Practice Address - Phone:561-988-0300
Practice Address - Fax:561-988-0350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2886152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620863100Medicaid
FL6602930001Medicare NSC
FL620863100Medicaid
FLCK396AMedicare PIN