Provider Demographics
NPI:1831822899
Name:COASTAL CLEAR EYECARE
Entity type:Organization
Organization Name:COASTAL CLEAR EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DEMETRIOS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:404-932-2802
Mailing Address - Street 1:133 RUM RUNNER WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2267
Mailing Address - Country:US
Mailing Address - Phone:404-932-2802
Mailing Address - Fax:
Practice Address - Street 1:155 FOUNTAINS WAY UNIT 11
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-1143
Practice Address - Country:US
Practice Address - Phone:404-932-2802
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-07
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty