Provider Demographics
NPI:1932247996
Name:JEROLD OPTICAL INC.
Entity Type:Organization
Organization Name:JEROLD OPTICAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:RUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:216-781-7900
Mailing Address - Street 1:800 HURON RD.
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-1121
Mailing Address - Country:US
Mailing Address - Phone:216-781-7900
Mailing Address - Fax:216-781-0554
Practice Address - Street 1:800 HURON RD E
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-1121
Practice Address - Country:US
Practice Address - Phone:216-781-7900
Practice Address - Fax:216-781-0554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1267-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4360507Medicaid
OH4360507Medicaid