Provider Demographics
NPI:1649342767
Name:THAYER EYE CARE PA
Entity type:Organization
Organization Name:THAYER EYE CARE PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:THAYER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:863-465-4904
Mailing Address - Street 1:27 US 27 S
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-7916
Mailing Address - Country:US
Mailing Address - Phone:863-465-4904
Mailing Address - Fax:863-465-4650
Practice Address - Street 1:27 US 27 S
Practice Address - Street 2:
Practice Address - City:LAKE PLACID
Practice Address - State:FL
Practice Address - Zip Code:33852-7916
Practice Address - Country:US
Practice Address - Phone:863-465-4904
Practice Address - Fax:863-465-4650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19418OtherBCBS OF FL
FLCM2511OtherRR MEDICARE
FLCM2511OtherRR MEDICARE
FLT96167Medicare UPIN
FLAH851Medicare PIN