Provider Demographics
NPI:1770741092
Name:PARK CENTRE OPTICAL
Entity type:Organization
Organization Name:PARK CENTRE OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NOE
Authorized Official - Suffix:
Authorized Official - Credentials:OPTICIAN
Authorized Official - Phone:330-335-3881
Mailing Address - Street 1:1 PARK CENTER DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WADSWORTH
Mailing Address - State:OH
Mailing Address - Zip Code:44281-7100
Mailing Address - Country:US
Mailing Address - Phone:330-335-3881
Mailing Address - Fax:330-334-9085
Practice Address - Street 1:1 PARK CENTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WADSWORTH
Practice Address - State:OH
Practice Address - Zip Code:44281-7100
Practice Address - Country:US
Practice Address - Phone:330-335-3881
Practice Address - Fax:330-334-9085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS2805332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0765266Medicaid
OH0694580001Medicare NSC