Provider Demographics
NPI:1609033323
Name:C R DECASTECKER OD INC
Entity Type:Organization
Organization Name:C R DECASTECKER OD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:R
Authorized Official - Last Name:DECASTECKER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-946-6662
Mailing Address - Street 1:34690 VINE ST
Mailing Address - Street 2:
Mailing Address - City:WILLOWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44095-5118
Mailing Address - Country:US
Mailing Address - Phone:440-946-6662
Mailing Address - Fax:440-946-6981
Practice Address - Street 1:34690 VINE ST
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-5118
Practice Address - Country:US
Practice Address - Phone:440-946-6662
Practice Address - Fax:440-946-6981
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2197046Medicaid
OH2197046Medicaid
OH4247290001Medicare NSC