MEDICARE: OPTOMETRIC MANAGEMENT GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1083369557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTOMETRIC MANAGEMENT GROUP LLC

Provider Business Mailing Address
First Line	:	265 N LIBERTY ST
Second Line	:
City	:	POWELL
State	:	OH
Zip	:	43065-8870
Country	:	US
Telephone Number	:	614-578-9797
Fax Number	:

Provider Business Practice Location Address
First Line	:	1049 BETHEL RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43220-2609
Country	:	US
Telephone Number	:	614-326-1830
Fax Number	:

Authorized Official
Title or Position	:	CHIEF VISIONARY OFFICER
Name	:	DR. TIMOTHY D. FRIES
Credential	:	OD, MBA, MPH
Telephone Number	:	614-517-9721

Provider Enumeration Date	:	02/14/2022
Last Update Date	:	02/14/2022

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