Provider Demographics
NPI:1912053547
Name:ST JOHNS EYE CARE P A
Entity type:Organization
Organization Name:ST JOHNS EYE CARE P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:LENNON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:386-328-5141
Mailing Address - Street 1:2504 CRILL AVE
Mailing Address - Street 2:
Mailing Address - City:PALATKA
Mailing Address - State:FL
Mailing Address - Zip Code:32177-4264
Mailing Address - Country:US
Mailing Address - Phone:386-328-5141
Mailing Address - Fax:386-328-3972
Practice Address - Street 1:2504 CRILL AVE
Practice Address - Street 2:
Practice Address - City:PALATKA
Practice Address - State:FL
Practice Address - Zip Code:32177-4264
Practice Address - Country:US
Practice Address - Phone:386-328-5141
Practice Address - Fax:386-328-3972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20061021152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122939400Medicaid
FL620005200Medicaid
FL0936440001Medicare NSC