Provider Demographics
NPI:1740040567
Name:HALE, GWEN
Entity type:Individual
Prefix:
First Name:GWEN
Middle Name:
Last Name:HALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9303 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-6413
Mailing Address - Country:US
Mailing Address - Phone:440-974-3303
Mailing Address - Fax:440-974-8898
Practice Address - Street 1:9303 MENTOR AVE
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-6413
Practice Address - Country:US
Practice Address - Phone:440-974-3303
Practice Address - Fax:440-974-8898
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017708-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician