Basic Information
| Provider Information | |||||||||
| NPI: | 1992004931 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TRI-STATE CENTERS FOR SIGHT INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRI-STATE CENTERS FOR SIGHT SURGERY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 SCOTT ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | COVINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410112420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595817120 | ||||||||
| FaxNumber: | 8595817207 | ||||||||
| Practice Location | |||||||||
| Address1: | 8044 MONTGOMERY RD | ||||||||
| Address2: | SUITE 155 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452362919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139363734 | ||||||||
| FaxNumber: | 5137911473 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 06/26/2013 | ||||||||
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| AuthorizedOfficialLastName: | NORDLOH | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8595817120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS0132X | N | Ambulatory Health Care Facilities | Clinic/Center | Ophthalmologic Surgery | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 0648204 | 05 | OH | MEDICAID |