Provider Demographics
NPI:1144699042
Name:FORT PIERCE VISION LLC
Entity type:Organization
Organization Name:FORT PIERCE VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:C
Authorized Official - Last Name:DESANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:954-821-1111
Mailing Address - Street 1:5100 OKEECHOBEE RD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34947-5428
Mailing Address - Country:US
Mailing Address - Phone:954-821-1111
Mailing Address - Fax:772-336-9017
Practice Address - Street 1:5100 OKEECHOBEE RD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-5428
Practice Address - Country:US
Practice Address - Phone:954-821-1111
Practice Address - Fax:772-336-9017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2169302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010527400Medicaid