Provider Demographics
NPI:1114055530
Name:EYE CLINIC OF WEST JEFFERSON, LLC
Entity Type:Organization
Organization Name:EYE CLINIC OF WEST JEFFERSON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:A
Authorized Official - Last Name:FURGERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-879-7239
Mailing Address - Street 1:487 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST JEFFERSON
Mailing Address - State:OH
Mailing Address - Zip Code:43162-1178
Mailing Address - Country:US
Mailing Address - Phone:614-879-7239
Mailing Address - Fax:614-879-1001
Practice Address - Street 1:487 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:43162-1178
Practice Address - Country:US
Practice Address - Phone:614-879-7239
Practice Address - Fax:614-879-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5388152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDD9476OtherMEDICARE RAILROAD
OH2436322Medicaid
OH9336241Medicare PIN
OHDD9476OtherMEDICARE RAILROAD
OH96013Medicare UPIN