Provider Demographics
NPI:1396960415
Name:PALM COAST EYEWEAR, LLC
Entity type:Organization
Organization Name:PALM COAST EYEWEAR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-794-2020
Mailing Address - Street 1:5601 21ST AVE W
Mailing Address - Street 2:SUITE C
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-5642
Mailing Address - Country:US
Mailing Address - Phone:941-794-1001
Mailing Address - Fax:941-794-3280
Practice Address - Street 1:5601 21ST AVE W
Practice Address - Street 2:SUITE C
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-5642
Practice Address - Country:US
Practice Address - Phone:941-794-1001
Practice Address - Fax:941-794-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO1765332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDO1765OtherOPTICIAN LICENSE
=========OtherTAX IDENTIFICATION
=========OtherTAX IDENTIFICATION