Provider Demographics
NPI:1528393717
Name:BEACHES EYE CENTER, PA
Entity type:Organization
Organization Name:BEACHES EYE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:DWIGHT
Authorized Official - Last Name:TEN HULZEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-246-3937
Mailing Address - Street 1:1351 13TH AVE S
Mailing Address - Street 2:SUITE 120-A
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3234
Mailing Address - Country:US
Mailing Address - Phone:904-246-3937
Mailing Address - Fax:904-242-0415
Practice Address - Street 1:1351 13TH AVE S
Practice Address - Street 2:SUITE 120-A
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250
Practice Address - Country:US
Practice Address - Phone:904-246-3937
Practice Address - Fax:904-242-0415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-06
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0080332207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL258859500Medicaid
FL35274Medicare PIN
FL258859500Medicaid