Provider Demographics
NPI:1376640821
Name:COSHOCTON VISION CENTER, LLC
Entity Type:Organization
Organization Name:COSHOCTON VISION CENTER, LLC
Other - Org Name:OPTICS PLUS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:FORNARA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-622-1484
Mailing Address - Street 1:224 CHESTNUT STREET
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1164
Mailing Address - Country:US
Mailing Address - Phone:740-622-1484
Mailing Address - Fax:740-622-1540
Practice Address - Street 1:224 CHESTNUT STREET
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1164
Practice Address - Country:US
Practice Address - Phone:740-622-1484
Practice Address - Fax:740-622-1540
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-19
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2873832Medicaid
OHCO9363991Medicare PIN
OHU26490Medicare UPIN
OH2873832Medicaid