MEDICARE: TWELVE THIRTY OPTICAL, INC.

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	332H00000X	Eyewear Supplier	SC1577	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	23706	OTHER	OH	SPECTERA
2	30569	OTHER	OH	DAVIS VISION
3	OH1577	OTHER	OH	EYE MED
4	141502	OTHER	OH	COLE MANAGED VISION

General Provider Information

NPI Number	:	1225159213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWELVE THIRTY OPTICAL, INC.

Provider Business Mailing Address
First Line	:	1117 MAGIE AVE
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-1823
Country	:	US
Telephone Number	:	513-829-8808
Fax Number	:	513-829-5305

Provider Business Practice Location Address
First Line	:	1117 MAGIE AVE
Second Line	:
City	:	FAIRFIELD
State	:	OH
Zip	:	45014-1823
Country	:	US
Telephone Number	:	513-829-8808
Fax Number	:	513-829-5305

Authorized Official
Title or Position	:	OWNER CONTACT LENS TECHNICIAN
Name	:	MRS. DONNA G IRVIN
Credential	:	LICENSED OPTICIAN
Telephone Number	:	513-829-8808

Provider Enumeration Date	:	04/03/2007
Last Update Date	:	08/22/2020

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