Provider Demographics
NPI:1881047850
Name:LOW VISION OF PANAMA CITY LLC
Entity type:Organization
Organization Name:LOW VISION OF PANAMA CITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUESADA MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-769-1404
Mailing Address - Street 1:826 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2526
Mailing Address - Country:US
Mailing Address - Phone:850-769-1404
Mailing Address - Fax:850-769-0748
Practice Address - Street 1:826 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2526
Practice Address - Country:US
Practice Address - Phone:850-769-1404
Practice Address - Fax:850-769-0748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5212152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Multi-Specialty
No152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty