Provider Demographics
NPI:1205085628
Name:THE EYE SITE IN COPLEY, LLC
Entity type:Organization
Organization Name:THE EYE SITE IN COPLEY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:HAZELWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:330-668-0150
Mailing Address - Street 1:3612 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333
Mailing Address - Country:US
Mailing Address - Phone:330-289-6206
Mailing Address - Fax:330-668-0967
Practice Address - Street 1:3612 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333
Practice Address - Country:US
Practice Address - Phone:330-289-6206
Practice Address - Fax:330-668-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5764152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHHA9378631Medicare PIN