Provider Demographics
NPI:1972707958
Name:TOTAL VISION OF PALM COAST INC
Entity Type:Organization
Organization Name:TOTAL VISION OF PALM COAST INC
Other - Org Name:TOTAL VISION EYE HEALTH ASSOC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:386-445-1880
Mailing Address - Street 1:15 CYPRESS BRANCH WAY
Mailing Address - Street 2:SUITE #205
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-8413
Mailing Address - Country:US
Mailing Address - Phone:386-445-1880
Mailing Address - Fax:386-445-8796
Practice Address - Street 1:15 CYPRESS BRANCH WAY
Practice Address - Street 2:SUITE #205
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-8413
Practice Address - Country:US
Practice Address - Phone:386-445-1880
Practice Address - Fax:386-445-8796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 0002395152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078287400Medicaid
FL078287400Medicaid
FLK5397Medicare ID - Type Unspecified