Provider Demographics
NPI:1881852804
Name:PROSPECT VISION CARE INC
Entity type:Organization
Organization Name:PROSPECT VISION CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHETVERIKOV
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-494-2999
Mailing Address - Street 1:100 E WATER ST
Mailing Address - Street 2:PO BOX 34
Mailing Address - City:PROSPECT
Mailing Address - State:OH
Mailing Address - Zip Code:43342-0034
Mailing Address - Country:US
Mailing Address - Phone:740-494-2999
Mailing Address - Fax:740-494-2999
Practice Address - Street 1:100 E WATER ST
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:OH
Practice Address - Zip Code:43342-0034
Practice Address - Country:US
Practice Address - Phone:740-494-2999
Practice Address - Fax:740-494-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4919152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2067963Medicaid
OHCH0859781Medicare PIN
OH0859781Medicare PIN
OH2067963Medicaid
OH1254480001Medicare NSC