Basic Information
| Provider Information | |||||||||
| NPI: | 1447356951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALEM EYECARE CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 616 E STATE ST | ||||||||
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| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444602935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303322080 | ||||||||
| FaxNumber: | 3303322123 | ||||||||
| Practice Location | |||||||||
| Address1: | 616 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444602935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303322080 | ||||||||
| FaxNumber: | 3303322123 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2006 | ||||||||
| LastUpdateDate: | 01/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | LIPPIATT | ||||||||
| AuthorizedOfficialFirstName: | LORIE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3303322080 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4031 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 2100121 | 05 | OH | MEDICAID |