Provider Demographics
NPI:1750761375
Name:CONGLETON EYE CARE, LLC
Entity type:Organization
Organization Name:CONGLETON EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONGLETON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:850-455-0722
Mailing Address - Street 1:4600 MOBILE HWY #9
Mailing Address - Street 2:PMB 139
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506
Mailing Address - Country:US
Mailing Address - Phone:850-455-0722
Mailing Address - Fax:850-455-0723
Practice Address - Street 1:4600 MOBILE HWY
Practice Address - Street 2:SUITE 122
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32506
Practice Address - Country:US
Practice Address - Phone:850-455-0722
Practice Address - Fax:850-455-0723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-09
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IG570ZOtherFLORIDA MEDICARE - INDIVIDUAL PTAN
FLIG569AOtherMEDICARE GROUP PTAN