Provider Demographics
NPI:1629240676
Name:PARKCREST OPTICAL COMPANY
Entity Type:Organization
Organization Name:PARKCREST OPTICAL COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ERIKSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-385-2361
Mailing Address - Street 1:3715 AIRPORT HWY
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-7173
Mailing Address - Country:US
Mailing Address - Phone:419-385-2361
Mailing Address - Fax:419-385-7460
Practice Address - Street 1:3715 AIRPORT HWY
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-7173
Practice Address - Country:US
Practice Address - Phone:419-385-2361
Practice Address - Fax:419-385-7460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-31
Last Update Date:2011-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH48141341332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2732814Medicaid
OH2732814Medicaid