Provider Demographics
NPI:1740431626
Name:ENGLEWOOD OPTOMETRY LLC
Entity Type:Organization
Organization Name:ENGLEWOOD OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:LOESCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-836-6621
Mailing Address - Street 1:621 WOODSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1838
Mailing Address - Country:US
Mailing Address - Phone:937-836-6621
Mailing Address - Fax:937-836-6621
Practice Address - Street 1:621 WOODSIDE DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1838
Practice Address - Country:US
Practice Address - Phone:937-836-6621
Practice Address - Fax:937-836-6621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3184T545152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH6220680001Medicare NSC
OH0445281Medicare UPIN