Provider Demographics
NPI:1003942434
Name:SAMUEL A. SEBASTIAN & GENE HRYCAK DBA OPTICAL VISION OF YOUNGSTOWN
Entity Type:Organization
Organization Name:SAMUEL A. SEBASTIAN & GENE HRYCAK DBA OPTICAL VISION OF YOUNGSTOWN
Other - Org Name:OPTICAL VISION OF YOUNGSTOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEBASTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:330-792-7045
Mailing Address - Street 1:2959 CANFIELD RD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-2800
Mailing Address - Country:US
Mailing Address - Phone:330-792-7045
Mailing Address - Fax:330-792-0038
Practice Address - Street 1:2959 CANFIELD RD
Practice Address - Street 2:SUITE #1
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-2800
Practice Address - Country:US
Practice Address - Phone:330-792-7045
Practice Address - Fax:330-792-0038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1800X
OHSC 198332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0668640001Medicare NSC