Provider Demographics
NPI:1639314537
Name:INNOVATIVE OPTICS INC.
Entity Type:Organization
Organization Name:INNOVATIVE OPTICS INC.
Other - Org Name:DR.MCCULLOUGHS VISION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-623-0110
Mailing Address - Street 1:618 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:COSHOCTON
Mailing Address - State:OH
Mailing Address - Zip Code:43812-1909
Mailing Address - Country:US
Mailing Address - Phone:740-623-0110
Mailing Address - Fax:740-623-0318
Practice Address - Street 1:618 S 2ND ST
Practice Address - Street 2:
Practice Address - City:COSHOCTON
Practice Address - State:OH
Practice Address - Zip Code:43812-1909
Practice Address - Country:US
Practice Address - Phone:740-623-0110
Practice Address - Fax:740-623-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-05
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2990152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0289500001Medicare NSC