Provider Demographics
NPI:1225282213
Name:BRUNSWICK EYE AND CONTACT LENS CENTER, LLC
Entity Type:Organization
Organization Name:BRUNSWICK EYE AND CONTACT LENS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:BRUNSWICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-782-3937
Mailing Address - Street 1:283 STADIUM DR
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-4604
Mailing Address - Country:US
Mailing Address - Phone:419-782-3937
Mailing Address - Fax:
Practice Address - Street 1:283 STADIUM DR
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-4604
Practice Address - Country:US
Practice Address - Phone:419-782-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4788152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBR9384321Medicare PIN
OH6354960001Medicare NSC