Provider Demographics
NPI:1659401180
Name:DR PATRICK HENRY OD LLC
Entity Type:Organization
Organization Name:DR PATRICK HENRY OD LLC
Other - Org Name:LIFETIME VISION CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:HOPE
Authorized Official - Middle Name:D
Authorized Official - Last Name:WCISLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-893-6841
Mailing Address - Street 1:109 WEST WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-2150
Mailing Address - Country:US
Mailing Address - Phone:419-893-6841
Mailing Address - Fax:419-893-4894
Practice Address - Street 1:109 WEST WAYNE ST
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-2150
Practice Address - Country:US
Practice Address - Phone:419-893-6841
Practice Address - Fax:419-893-4894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5163 T2062152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH5163 T2062OtherSTATE LICENSE NUMBER
OH2196672Medicaid
OH9328491Medicare PIN
OHU81596Medicare UPIN
OHDB9390Medicare PIN
OH5163 T2062OtherSTATE LICENSE NUMBER