Provider Demographics
NPI:1376790790
Name:BURCHETT, CAROLYN ANN (LDO)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:ANN
Last Name:BURCHETT
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2164 TREMAINSVILLE RD.
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43613
Mailing Address - Country:US
Mailing Address - Phone:419-474-6699
Mailing Address - Fax:
Practice Address - Street 1:2164 TREMAINSVILLE RD.
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43613
Practice Address - Country:US
Practice Address - Phone:419-474-6699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5253156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician