Provider Demographics
NPI:1245476191
Name:MODERN EYECARE LLC
Entity type:Organization
Organization Name:MODERN EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOY
Authorized Official - Middle Name:M
Authorized Official - Last Name:ELLERBROCK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-615-3802
Mailing Address - Street 1:PO BOX 42
Mailing Address - Street 2:
Mailing Address - City:CONTINENTAL
Mailing Address - State:OH
Mailing Address - Zip Code:45831-0042
Mailing Address - Country:US
Mailing Address - Phone:419-596-3062
Mailing Address - Fax:
Practice Address - Street 1:301 E STATE ROUTE 613
Practice Address - Street 2:
Practice Address - City:CONTINENTAL
Practice Address - State:OH
Practice Address - Zip Code:45831-9133
Practice Address - Country:US
Practice Address - Phone:419-596-3062
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-24
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDR1222Medicare PIN
OH6210450001Medicare NSC
OH9380961Medicare PIN