| Organization Name: | EASTGATE VISION CENTER |
| NPI Number: | 1689845471 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MARSHA LYNN ROACH (OPTICIAN) |
| Mailing Address: | 164 Hwy 17 South Suite 12-c Eastgate Vision Center East Palatka |
| State: | FL US |
| Postal Code: | 32131 |
| Phone Number: | 3863282008 |
| Fax Number: | 3863282008 |
| NPI Enumeration Date: | 03/19/2008 |
| NPI Last Update Date: | 09/24/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 156FX1800X |
| License Number: | D01128 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | FL |
| Taxonomy Type: | Eye and Vision Services Providers |
| Taxonomy Classification: | Technician/Technologist |
| Taxonomy Specialization: | Optician |
| Taxonomy Definition: | |