Provider Demographics
NPI:1932320447
Name:EYE SITE, L.L.C.
Entity Type:Organization
Organization Name:EYE SITE, L.L.C.
Other - Org Name:THE EYE SITE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-587-4970
Mailing Address - Street 1:114 N GALWAY DR
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43023-9572
Mailing Address - Country:US
Mailing Address - Phone:740-587-4970
Mailing Address - Fax:740-587-4863
Practice Address - Street 1:114 N GALWAY DR
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:OH
Practice Address - Zip Code:43023-9572
Practice Address - Country:US
Practice Address - Phone:740-587-4970
Practice Address - Fax:740-587-4863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2235414Medicaid
OH0294346Medicaid
OH0294346Medicaid
4029153Medicare PIN
9316051Medicare PIN
OH2235414Medicaid
1356441802Medicare PIN
U81255Medicare UPIN
1205926318Medicare PIN
0816924Medicare PIN
4329420001Medicare NSC