# LASERVUE EYE CENTER A MEDICAL CORPORATION

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1811372568
- **Authorized official:** NICOLE SISKO (CREDENTIALING SPECIALIST)
- **Authorized official phone:** (727) 483-7463

## Contact information

- **Practice address:** 3450 MENDOCINO AVE, 200, SANTA ROSA, CA 95403-2221
- **Practice address phone:** (707) 522-6200
- **Practice address fax:** (707) 522-6215
- **Mailing address:** 311 PARK PLACE BLVD, 5TH FLOOR, CLEARWATER, FL 33759-4904
- **Mailing address phone:** (727) 483-7463
- **Mailing address fax:** (727) 755-0679

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 332900000X | Non-Pharmacy Dispensing Site | G66178 | CA | Yes |

## Other

- **Enumeration date:** 07/23/2015
- **Last updated:** 07/23/2015