Provider Demographics
NPI:1619064177
Name:FOSTORIA EYECARE INC
Entity Type:Organization
Organization Name:FOSTORIA EYECARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:W
Authorized Official - Last Name:SKULINA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-435-3323
Mailing Address - Street 1:799 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830
Mailing Address - Country:US
Mailing Address - Phone:419-435-3323
Mailing Address - Fax:419-435-7834
Practice Address - Street 1:799 N VINE ST
Practice Address - Street 2:FOSTORIA EYECARE INC
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830
Practice Address - Country:US
Practice Address - Phone:419-435-3323
Practice Address - Fax:419-435-7834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4314 T655152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0921924Medicaid
OH1309850001Medicare PIN
OH1309850001Medicare NSC
OH0921924Medicaid