Provider Demographics
NPI:1376919704
Name:DOUGLAS WINE FAMILY OPTOMETRY, INC.
Entity Type:Organization
Organization Name:DOUGLAS WINE FAMILY OPTOMETRY, INC.
Other - Org Name:EPIC EYES
Other - Org Type:Other Name
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:
Authorized Official - First Name:CLARINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-305-7283
Mailing Address - Street 1:227 CANDLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-9661
Mailing Address - Country:US
Mailing Address - Phone:419-305-7283
Mailing Address - Fax:
Practice Address - Street 1:140 W SPRING ST
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-2312
Practice Address - Country:US
Practice Address - Phone:419-305-7283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140106332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier