Provider Demographics
NPI:1912187402
Name:INNOVATIVE VISION LLC
Entity Type:Organization
Organization Name:INNOVATIVE VISION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORCORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-793-8486
Mailing Address - Street 1:9797 MONTGOMERY ROAD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7247
Mailing Address - Country:US
Mailing Address - Phone:513-793-8486
Mailing Address - Fax:513-793-2023
Practice Address - Street 1:9797 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-7247
Practice Address - Country:US
Practice Address - Phone:513-793-8486
Practice Address - Fax:513-793-2023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-13
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5396152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2225729Medicaid
OH4655840001Medicare NSC
OH9309951Medicare PIN
OHKV4130741Medicare UPIN