Provider Demographics
NPI:1265797138
Name:PREMIER VISUAL HEALTH, LLC
Entity type:Organization
Organization Name:PREMIER VISUAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:JUANA
Authorized Official - Middle Name:P
Authorized Official - Last Name:CETINA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-352-4044
Mailing Address - Street 1:810 N ROSE AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4944
Mailing Address - Country:US
Mailing Address - Phone:407-352-4044
Mailing Address - Fax:407-352-4043
Practice Address - Street 1:810 N ROSE AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4944
Practice Address - Country:US
Practice Address - Phone:407-352-4044
Practice Address - Fax:407-352-4043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-06
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86805207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL266163200Medicaid
FLB41831Medicare UPIN
FL51310OtherBLUE CROSS BLUE SHIELD
FLGH743AOtherMEDICARE PTAN
FLH25829Medicare UPIN