Basic Information
| Provider Information | |||||||||
| NPI: | 1710030242 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNION VISION CENTER OF STOW, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CO-OP OPTICAL EYE CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3330 KENT RD | ||||||||
| Address2: | |||||||||
| City: | STOW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442244536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306888244 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3330 KENT RD | ||||||||
| Address2: | |||||||||
| City: | STOW | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442244537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306888244 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 05/22/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MINKIN | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3306888244 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | 77149067 | OH | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
ID Information
| ID | Type | State | Issuer | Description | 0289263 | 05 | OH | MEDICAID |