Provider Demographics
NPI:1023111036
Name:ADVANCED EYE CARE OF HIALEAH, PA
Entity type:Organization
Organization Name:ADVANCED EYE CARE OF HIALEAH, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:POMELLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:305-556-6946
Mailing Address - Street 1:5952 W 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-6814
Mailing Address - Country:US
Mailing Address - Phone:305-556-6946
Mailing Address - Fax:305-825-0845
Practice Address - Street 1:5952 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-6814
Practice Address - Country:US
Practice Address - Phone:305-556-6946
Practice Address - Fax:305-825-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3040152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL621004000Medicaid
FLK7724Medicare PIN