Provider Demographics
NPI:1710150347
Name:POWELL VISION CLINIC, LLC
Entity Type:Organization
Organization Name:POWELL VISION CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:G
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-698-4949
Mailing Address - Street 1:3975 NAVARRE AVE
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-3437
Mailing Address - Country:US
Mailing Address - Phone:419-698-4949
Mailing Address - Fax:419-698-9948
Practice Address - Street 1:3975 NAVARRE AVE
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-3437
Practice Address - Country:US
Practice Address - Phone:419-698-4949
Practice Address - Fax:419-698-9948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-03
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0418613Medicaid
OH0418613Medicaid