Provider Demographics
NPI:1083369557
Name:OPTOMETRIC MANAGEMENT GROUP LLC
Entity Type:Organization
Organization Name:OPTOMETRIC MANAGEMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF VISIONARY OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FRIES
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MBA, MPH
Authorized Official - Phone:614-517-9721
Mailing Address - Street 1:265 N LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43065-8870
Mailing Address - Country:US
Mailing Address - Phone:614-578-9797
Mailing Address - Fax:
Practice Address - Street 1:1049 BETHEL RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43220-2609
Practice Address - Country:US
Practice Address - Phone:614-326-1830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty