Provider Demographics
NPI:1033391958
Name:WAYNESBURG VISION CARE LTD
Entity Type:Organization
Organization Name:WAYNESBURG VISION CARE LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:KAIL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-866-7732
Mailing Address - Street 1:PO BOX 447
Mailing Address - Street 2:
Mailing Address - City:WAYNESBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44688-0447
Mailing Address - Country:US
Mailing Address - Phone:330-866-7732
Mailing Address - Fax:330-866-4069
Practice Address - Street 1:8163 WAYNESBURG DR. SE
Practice Address - Street 2:
Practice Address - City:WAYNESBURG
Practice Address - State:OH
Practice Address - Zip Code:44688
Practice Address - Country:US
Practice Address - Phone:330-866-7732
Practice Address - Fax:330-866-4069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0302505Medicaid
6135930001Medicare NSC
OH9372421Medicare PIN
OH0302505Medicaid