Provider Demographics
NPI:1023204559
Name:AMBROSE FAMILY EYE CENTER,LLC
Entity Type:Organization
Organization Name:AMBROSE FAMILY EYE CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FRANK
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-702-0503
Mailing Address - Street 1:61 TALSMAN DR
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-1207
Mailing Address - Country:US
Mailing Address - Phone:330-702-0503
Mailing Address - Fax:330-533-6111
Practice Address - Street 1:61 TALSMAN DR
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-1207
Practice Address - Country:US
Practice Address - Phone:330-702-0503
Practice Address - Fax:330-533-6111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2008-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5192152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5258970001Medicare NSC
OHAM9335791Medicare PIN