Provider Demographics
NPI:1407918311
Name:ELDER CARE VISION SERVICES INC
Entity Type:Organization
Organization Name:ELDER CARE VISION SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-237-6964
Mailing Address - Street 1:12794 ROYALTON RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-4229
Mailing Address - Country:US
Mailing Address - Phone:440-237-6964
Mailing Address - Fax:440-237-4605
Practice Address - Street 1:12794 ROYALTON RD
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-4229
Practice Address - Country:US
Practice Address - Phone:440-237-6964
Practice Address - Fax:440-237-4605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2375595Medicaid
U56848Medicare UPIN
OH9331381Medicare PIN