Provider Demographics
NPI:1659920189
Name:BRUNSWICK OPTICAL
Entity Type:Organization
Organization Name:BRUNSWICK OPTICAL
Other - Org Name:BRUNSWICK OPTICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:GRUCELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:216-571-0726
Mailing Address - Street 1:1486 WATERBURY RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4817
Mailing Address - Country:US
Mailing Address - Phone:216-571-0726
Mailing Address - Fax:
Practice Address - Street 1:1333 N CARPENTER RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3178
Practice Address - Country:US
Practice Address - Phone:330-741-3407
Practice Address - Fax:330-741-4037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-07
Last Update Date:2019-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty