Provider Demographics
NPI:1306035142
Name:FAMILY VISION CARE OF WAVERLY INC
Entity Type:Organization
Organization Name:FAMILY VISION CARE OF WAVERLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:G
Authorized Official - Last Name:MONTAVON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-947-8191
Mailing Address - Street 1:414 W EMMITT AVE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-1008
Mailing Address - Country:US
Mailing Address - Phone:740-947-8191
Mailing Address - Fax:740-947-5554
Practice Address - Street 1:414 W EMMITT AVE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-1008
Practice Address - Country:US
Practice Address - Phone:740-947-8191
Practice Address - Fax:740-947-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3556/T794152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0471976Medicaid
OHT47793Medicare UPIN
OH0471976Medicaid
OH5109630001Medicare NSC