Provider Demographics
NPI:1295531481
Name:OHIO EYE OPTOMETRIC, LLC
Entity type:Organization
Organization Name:OHIO EYE OPTOMETRIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-774-3402
Mailing Address - Street 1:466 S TRIMBLE RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44906-3416
Mailing Address - Country:US
Mailing Address - Phone:419-756-8000
Mailing Address - Fax:419-756-2601
Practice Address - Street 1:110 COSHOCTON AVE STE C
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-2628
Practice Address - Country:US
Practice Address - Phone:419-756-8000
Practice Address - Fax:419-756-2601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OHIO EYE OPTOMETRIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS3838OtherNON MEDICARE