1639264872 NPI number — LAKE ERIE FAMILY EYECARE LLC

Table of content: (NPI 1639264872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639264872 NPI number — LAKE ERIE FAMILY EYECARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE ERIE FAMILY EYECARE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639264872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 JEFFERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORT CLINTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43452-1141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-734-2106
Provider Business Mailing Address Fax Number:
419-734-3792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CLINTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43452-1141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-734-2106
Provider Business Practice Location Address Fax Number:
419-734-3792
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FELBINGER
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
419-734-2106

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  3027/T449 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02487 . This is a "PARAMOUNT HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2284611 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300709331004 . This is a "MEDICAL MUTUAL OF OHIO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 04231 . This is a "PARAMOUNT HEALTH CARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 298423149006 . This is a "MEDICAL MUTUAL OF OHIO" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000510602 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000519919 . This is a "ANTHEM BCBS" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 0257181 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2628704 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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