Provider Demographics
NPI:1811372568
Name:LASERVUE EYE CENTER A MEDICAL CORPORATION
Entity type:Organization
Organization Name:LASERVUE EYE CENTER A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:SISKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-483-7463
Mailing Address - Street 1:311 PARK PLACE BLVD
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-4904
Mailing Address - Country:US
Mailing Address - Phone:727-483-7463
Mailing Address - Fax:727-755-0679
Practice Address - Street 1:3450 MENDOCINO AVE
Practice Address - Street 2:200
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2221
Practice Address - Country:US
Practice Address - Phone:707-522-6200
Practice Address - Fax:707-522-6215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-23
Last Update Date:2015-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG66178332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAV544Medicare UPIN