Provider Demographics
NPI:1578760468
Name:DISTINCTIVE EYEWEAR INC.
Entity Type:Organization
Organization Name:DISTINCTIVE EYEWEAR INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MENTESSI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-877-2020
Mailing Address - Street 1:5690 WALLINGS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-3044
Mailing Address - Country:US
Mailing Address - Phone:440-877-2020
Mailing Address - Fax:440-877-9531
Practice Address - Street 1:5690 WALLINGS RD
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-3044
Practice Address - Country:US
Practice Address - Phone:440-877-2020
Practice Address - Fax:440-877-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5054152W00000X
OH156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDU3948Medicare PIN
OHU79061Medicare UPIN
OH5990580001Medicare NSC
OH9372431Medicare PIN