Provider Demographics
NPI:1225425044
Name:EYETIQUE OF CLEVELAND
Entity Type:Organization
Organization Name:EYETIQUE OF CLEVELAND
Other - Org Name:CO OP OPTICAL CENTER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-462-9818
Mailing Address - Street 1:3330 KENT RD
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-4537
Mailing Address - Country:US
Mailing Address - Phone:330-688-8244
Mailing Address - Fax:
Practice Address - Street 1:1201 BANKSVILLE RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15216
Practice Address - Country:US
Practice Address - Phone:412-668-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-20
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier