Provider Demographics
NPI:1841230075
Name:ADVANCED EYECARE & SPORTS VISION CENTER, INC.
Entity Type:Organization
Organization Name:ADVANCED EYECARE & SPORTS VISION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-873-1003
Mailing Address - Street 1:302 WEST MAIN ST., STE 100
Mailing Address - Street 2:
Mailing Address - City:PLAIN CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43064
Mailing Address - Country:US
Mailing Address - Phone:614-873-1003
Mailing Address - Fax:
Practice Address - Street 1:302 WEST MAIN ST., STE 100
Practice Address - Street 2:
Practice Address - City:PLAIN CITY
Practice Address - State:OH
Practice Address - Zip Code:43064
Practice Address - Country:US
Practice Address - Phone:614-873-1003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2009-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4217/T949152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH278681842004OtherMEDICAL MUTUAL
DC0168OtherRAILROAD MEDICARE
OH0924450Medicaid
OH000000224728OtherANTHEM
OH2200301OtherUNITED HEALTHCARE
OH5452035OtherAETNA
OH5452035OtherAETNA
4925970001Medicare NSC
OH2200301OtherUNITED HEALTHCARE
OH0924450Medicaid