Basic Information
| Provider Information | |||||||||
| NPI: | 1144462862 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WOODY WILLIAMS VISION CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | TOWNE OPTICAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3600 TOWNE BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FRANKLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450055543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134245217 | ||||||||
| FaxNumber: | 5134240205 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 TOWNE BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | FRANKLIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450055543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134245217 | ||||||||
| FaxNumber: | 5134240205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2009 | ||||||||
| LastUpdateDate: | 03/26/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | WOODY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5134245217 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LICENSED OPTICIAN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 2467SC | OH | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 0259107 | 05 | OH | MEDICAID |