Provider Demographics
NPI:1952604290
Name:FAMILY EYE CENTER SOUTH LLC
Entity Type:Organization
Organization Name:FAMILY EYE CENTER SOUTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:B
Authorized Official - Last Name:TRAWICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:863-644-7773
Mailing Address - Street 1:5125 S. LAKELAND DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2578
Mailing Address - Country:US
Mailing Address - Phone:863-644-7773
Mailing Address - Fax:863-646-2809
Practice Address - Street 1:5125 S. LAKELAND DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2578
Practice Address - Country:US
Practice Address - Phone:863-644-7773
Practice Address - Fax:863-646-2809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC-1885152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6501410001Medicare NSC
FLED617AMedicare PIN
FLDQ8966Medicare PIN