Provider Demographics
NPI:1982972410
Name:COFFMAN OPTICAL, LLC
Entity Type:Organization
Organization Name:COFFMAN OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:D
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:LDO
Authorized Official - Phone:330-343-1215
Mailing Address - Street 1:130 S BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:NEW PHILADELPHIA
Mailing Address - State:OH
Mailing Address - Zip Code:44663-3829
Mailing Address - Country:US
Mailing Address - Phone:330-343-1215
Mailing Address - Fax:330-343-3673
Practice Address - Street 1:130 S BROADWAY ST
Practice Address - Street 2:
Practice Address - City:NEW PHILADELPHIA
Practice Address - State:OH
Practice Address - Zip Code:44663-3829
Practice Address - Country:US
Practice Address - Phone:330-343-1215
Practice Address - Fax:330-343-3673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-12
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4045S156FX1800X, 332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0062829Medicaid
OH0062829Medicaid