Provider Demographics
NPI:1730689530
Name:MICHAEL PENNACHIO, LLC
Entity type:Organization
Organization Name:MICHAEL PENNACHIO, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNACHIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-227-1999
Mailing Address - Street 1:14244 SR 50
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-8003
Mailing Address - Country:US
Mailing Address - Phone:352-227-1999
Mailing Address - Fax:
Practice Address - Street 1:1100 S GROVE ST
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-5524
Practice Address - Country:US
Practice Address - Phone:352-227-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHAEL PENNACHIO, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME45426207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty