Provider Demographics
NPI:1710166590
Name:COURTNEY L POLING OD
Entity Type:Organization
Organization Name:COURTNEY L POLING OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:POLING
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-644-2075
Mailing Address - Street 1:PO BOX 396
Mailing Address - Street 2:303 W FIFTH ST
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-0396
Mailing Address - Country:US
Mailing Address - Phone:937-644-2075
Mailing Address - Fax:937-644-2017
Practice Address - Street 1:303 W FIFTH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-0396
Practice Address - Country:US
Practice Address - Phone:937-644-2075
Practice Address - Fax:937-644-2017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2995T96152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09327131OtherMEDICARE GROUP NUMBER