Provider Demographics
NPI:1013027317
Name:VISUAL HEALTH AT JUPITER EYE CENTER LLC
Entity Type:Organization
Organization Name:VISUAL HEALTH AT JUPITER EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTARTOR
Authorized Official - Prefix:
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:COFFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-227-3101
Mailing Address - Street 1:2889 10TH AVE N
Mailing Address - Street 2:STE 305
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-3045
Mailing Address - Country:US
Mailing Address - Phone:561-964-0707
Mailing Address - Fax:561-227-3183
Practice Address - Street 1:102 COASTAL WAY
Practice Address - Street 2:#103
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33477-5004
Practice Address - Country:US
Practice Address - Phone:561-747-1111
Practice Address - Fax:561-744-6682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK3301Medicare PIN