Provider Demographics
NPI:1497357081
Name:NEWARK VISION CARE LLC
Entity Type:Organization
Organization Name:NEWARK VISION CARE LLC
Other - Org Name:TRILLIUM VISION CARE OF NEW LEXINGTON, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT/OWNDER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:RYEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-893-8114
Mailing Address - Street 1:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-0540
Mailing Address - Country:US
Mailing Address - Phone:740-342-1784
Mailing Address - Fax:740-342-1791
Practice Address - Street 1:391 LINCOLN PARK DR
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1080
Practice Address - Country:US
Practice Address - Phone:740-342-1784
Practice Address - Fax:740-342-1791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-10
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0425236Medicaid