Basic Information
| Provider Information | |||||||||
| NPI: | 1174619373 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN RESERVE VISION CARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN RESERVE VISION CARE HUDSON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5992 DARROW RD. | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306509599 | ||||||||
| FaxNumber: | 3306502139 | ||||||||
| Practice Location | |||||||||
| Address1: | 5992 DARROW RD. | ||||||||
| Address2: | |||||||||
| City: | HUDSON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306509599 | ||||||||
| FaxNumber: | 3306502139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/02/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STIEGEMEIER | ||||||||
| AuthorizedOfficialFirstName: | MARY JO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT / CEO | ||||||||
| AuthorizedOfficialTelephone: | 3306509599 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist | 152W00000X | 3694 | OH | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.