Basic Information
| Provider Information | |||||||||
| NPI: | 1043291966 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL EYE CARE ASSOCIATES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 553 E TOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144611885 | ||||||||
| FaxNumber: | 6144615730 | ||||||||
| Practice Location | |||||||||
| Address1: | 553 E TOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6144611885 | ||||||||
| FaxNumber: | 6144615730 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 08/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | DICKSON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6144611885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.