Provider Demographics
NPI:1104000520
Name:AHLQUIST EYE CARE PROFESSIONALS, LLC.
Entity Type:Organization
Organization Name:AHLQUIST EYE CARE PROFESSIONALS, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BETSY
Authorized Official - Middle Name:K
Authorized Official - Last Name:AHLQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-702-3937
Mailing Address - Street 1:45 MANOR HILL DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-1538
Mailing Address - Country:US
Mailing Address - Phone:330-702-3937
Mailing Address - Fax:330-702-1911
Practice Address - Street 1:45 MANOR HILL DR STE 100
Practice Address - Street 2:
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-1538
Practice Address - Country:US
Practice Address - Phone:330-702-3937
Practice Address - Fax:330-702-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5455152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDE8432OtherMEDICARE RAILROAD
OHDE8432OtherMEDICARE RAILROAD
OHDE8432OtherMEDICARE RAILROAD