Provider Demographics
NPI:1669500161
Name:PROFESSIONAL OPTICAL CO
Entity Type:Organization
Organization Name:PROFESSIONAL OPTICAL CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:C
Authorized Official - Last Name:RIFFLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-974-9449
Mailing Address - Street 1:9485 MENTOR AVE
Mailing Address - Street 2:STE111
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-4597
Mailing Address - Country:US
Mailing Address - Phone:440-974-9449
Mailing Address - Fax:440-255-1550
Practice Address - Street 1:9485 MENTOR AVE
Practice Address - Street 2:STE111
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-4597
Practice Address - Country:US
Practice Address - Phone:440-974-9449
Practice Address - Fax:440-255-1550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH43048581156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0322970001Medicare ID - Type Unspecified