Provider Demographics
NPI:1982794368
Name:ADVANCED EYE CARE AND OPTICAL INC
Entity Type:Organization
Organization Name:ADVANCED EYE CARE AND OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:POWERS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:904-996-1533
Mailing Address - Street 1:3546 SAINT JOHNS BLUFF RD S
Mailing Address - Street 2:UNIT 203
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2713
Mailing Address - Country:US
Mailing Address - Phone:904-996-1533
Mailing Address - Fax:904-996-1535
Practice Address - Street 1:3546 ST JOHNS BLUFF RD S
Practice Address - Street 2:UNIT 203
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224
Practice Address - Country:US
Practice Address - Phone:904-996-1533
Practice Address - Fax:904-996-1535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3509152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620752900Medicaid
FL20725OtherBLUECROSS BLUESHIELD
FL=========OtherTAX ID
FLAE858Medicare PIN
FL=========OtherTAX ID
FL20725OtherBLUECROSS BLUESHIELD