MEDICARE: COSHOCTON VISION CENTER, 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	5622	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1801104260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COSHOCTON VISION CENTER, LLC

Provider Business Mailing Address
First Line	:	95 W DAVE LONGABERGER AVE
Second Line	:
City	:	DRESDEN
State	:	OH
Zip	:	43821-9687
Country	:	US
Telephone Number	:	740-754-3800
Fax Number	:	740-754-2050

Provider Business Practice Location Address
First Line	:	95 W DAVE LONGABERGER AVE
Second Line	:
City	:	DRESDEN
State	:	OH
Zip	:	43821-9687
Country	:	US
Telephone Number	:	740-754-3800
Fax Number	:	740-754-2050

Authorized Official
Title or Position	:	MEMBER / OWNER
Name	:	CHARLES WILLIAM FORNARA
Credential	:	OD
Telephone Number	:	740-622-1484

Provider Enumeration Date	:	09/20/2010
Last Update Date	:	10/16/2019

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