Basic Information
| Provider Information | |||||||||
| NPI: | 1114083938 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GALLOWAY EYE CARE PROFESSIONALS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5670 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | GALLOWAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431198127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148532020 | ||||||||
| FaxNumber: | 6148530154 | ||||||||
| Practice Location | |||||||||
| Address1: | 5670 W BROAD ST | ||||||||
| Address2: | |||||||||
| City: | GALLOWAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431198127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6148532020 | ||||||||
| FaxNumber: | 6148530154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MATTSON | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6148532020 | ||||||||
| 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 | 5635 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.