Healthcare Provider Details

I. General information

NPI: 1265881643
Provider Name (Legal Business Name): CHELSEA LOCY-FOWLER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 STATE RD
ASHTABULA OH
44004-5957
US

IV. Provider business mailing address

3224 NINETY RD
ASHTABULA OH
44004-9606
US

V. Phone/Fax

Practice location:
  • Phone: 440-997-2020
  • Fax:
Mailing address:
  • Phone: 440-474-3106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT. 6477.
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003218
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: