Provider Demographics
NPI:1316249824
Name:EYE SITE VISION CENTER INC
Entity type:Organization
Organization Name:EYE SITE VISION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:GOBERVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-344-3937
Mailing Address - Street 1:2344 N UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5122
Mailing Address - Country:US
Mailing Address - Phone:954-344-3937
Mailing Address - Fax:954-344-2434
Practice Address - Street 1:2344 N UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5122
Practice Address - Country:US
Practice Address - Phone:954-344-3937
Practice Address - Fax:954-344-2434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FMOPC2575152WP0200X
FLOPC2575152WS0006X, 152WV0400X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No152WS0006XEye and Vision Services ProvidersOptometristSports VisionGroup - Multi-Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicare PIN