1124136189 NPI number — THE EYE CLINIC, INC.

Table of content: (NPI 1124136189)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124136189 NPI number — THE EYE CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE EYE CLINIC, INC.
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:
PERRY EYE CLINIC INC
Provider Other Organization Name Type Code:
4
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:
1124136189
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3545 LINCOLN WAY E
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
MASSILLON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44646-8624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-837-5191
Provider Business Mailing Address Fax Number:
330-837-0755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3545 LINCOLN WAY E
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MASSILLON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44646-8624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-837-5191
Provider Business Practice Location Address Fax Number:
330-837-0755
Provider Enumeration Date:
08/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOOD
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
330-837-5191

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0935895 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: CM0456 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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