Provider Demographics
NPI:1194969907
Name:FAMILY EYE CARE OF WESTSHORE P.L.
Entity type:Organization
Organization Name:FAMILY EYE CARE OF WESTSHORE P.L.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:813-286-0433
Mailing Address - Street 1:4040 W KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-2750
Mailing Address - Country:US
Mailing Address - Phone:813-286-0433
Mailing Address - Fax:813-286-0498
Practice Address - Street 1:4040 W KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2750
Practice Address - Country:US
Practice Address - Phone:813-286-0433
Practice Address - Fax:813-286-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1473152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078017100Medicaid
FLBU143AMedicare PIN
FL6214220001Medicare NSC