Provider Demographics
NPI:1609914829
Name:RGM OPTICAL SRV INC
Entity Type:Organization
Organization Name:RGM OPTICAL SRV INC
Other - Org Name:EYE X CARE OPTICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT LDO
Authorized Official - Prefix:MR
Authorized Official - First Name:REY
Authorized Official - Middle Name:G
Authorized Official - Last Name:MALONJAO
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSING DISPENSING
Authorized Official - Phone:937-237-8669
Mailing Address - Street 1:6079 BRANDT PIKE
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424
Mailing Address - Country:US
Mailing Address - Phone:937-237-8669
Mailing Address - Fax:937-237-9019
Practice Address - Street 1:6079 BRANDT PIKE
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424
Practice Address - Country:US
Practice Address - Phone:937-237-8669
Practice Address - Fax:937-237-9019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4554152W00000X
OHS5371156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Not Answered156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2480668Medicaid