Provider Demographics
NPI:1255055646
Name:EDISON EYE CARE, PLLC
Entity type:Organization
Organization Name:EDISON EYE CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KONYNENBELT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:616-834-2598
Mailing Address - Street 1:1214 SWEETWATER LN UNIT 2305
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-4177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19527 HIGHLAND OAKS DR STE 203
Practice Address - Street 2:
Practice Address - City:ESTERO
Practice Address - State:FL
Practice Address - Zip Code:33928-9637
Practice Address - Country:US
Practice Address - Phone:616-834-2598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-28
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Single Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty