Provider Demographics
NPI:1376735118
Name:PORTAGE VISION CARE LLC
Entity Type:Organization
Organization Name:PORTAGE VISION CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-296-0100
Mailing Address - Street 1:950 E MAIN ST
Mailing Address - Street 2:PO BOX 1021
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3326
Mailing Address - Country:US
Mailing Address - Phone:330-296-0100
Mailing Address - Fax:330-296-0105
Practice Address - Street 1:950 E MAIN ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3326
Practice Address - Country:US
Practice Address - Phone:330-296-0100
Practice Address - Fax:330-296-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-15
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4291T63152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5216050001Medicare NSC
OHU25110Medicare UPIN
OH9331521Medicare PIN