Basic Information
| Provider Information | |||||||||
| NPI: | 1134255474 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLAGE EYE CARE, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 263 | ||||||||
| Address2: | 1001 MONROE RD. | ||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450360263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139342020 | ||||||||
| FaxNumber: | 5139342028 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 MONROE RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450361414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139342020 | ||||||||
| FaxNumber: | 5139342028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 09/30/2021 | ||||||||
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| AuthorizedOfficialLastName: | KERBY | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | SUE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5139342020 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
| NPICertificationDate: | 09/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4756 | OH | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | 4755 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 0005706630 | 01 | OH | AETNA | OTHER | 2054799 | 05 | OH | MEDICAID |