Provider Demographics
NPI:1386710937
Name:MONTGOMERY EYE CENTER, LLC
Entity type:Organization
Organization Name:MONTGOMERY EYE CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LIBERTINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-480-2135
Mailing Address - Street 1:1360 E VENICE AVE
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285-9066
Mailing Address - Country:US
Mailing Address - Phone:941-480-2020
Mailing Address - Fax:941-484-2200
Practice Address - Street 1:700 NEAPOLITAN WAY
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34103-8570
Practice Address - Country:US
Practice Address - Phone:239-261-8383
Practice Address - Fax:239-261-8443
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTGOMERY EYE CENTER, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-27
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL999261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL999OtherAHCA STATE LICENSE NUMBER
FLF1048Medicare ID - Type UnspecifiedASC MEDICARE NUMBER