Provider Demographics
NPI:1598926594
Name:PROCARE OF TROY LLC
Entity Type:Organization
Organization Name:PROCARE OF TROY LLC
Other - Org Name:PROCARE VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-339-7956
Mailing Address - Street 1:1861 TOWNE PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2067
Mailing Address - Country:US
Mailing Address - Phone:937-339-7956
Mailing Address - Fax:937-339-6860
Practice Address - Street 1:1861 TOWNE PARK DR STE A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2067
Practice Address - Country:US
Practice Address - Phone:937-339-7956
Practice Address - Fax:937-339-6860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-23
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4494 & 4311152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6290500001Medicare NSC
OHDU9984Medicare PIN
OH9319712Medicare PIN