Healthcare Provider Details

I. General information

NPI: 1578881009
Provider Name (Legal Business Name): EYE LASER AND SURGERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 INDIAN RIPPLE RD STE 110
BEAVERCREEK OH
45440-3265
US

IV. Provider business mailing address

4235 INDIAN RIPPLE RD STE 110
BEAVERCREEK OH
45440-3265
US

V. Phone/Fax

Practice location:
  • Phone: 937-427-7800
  • Fax: 937-427-7803
Mailing address:
  • Phone: 937-427-7800
  • Fax: 937-427-7803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number0991AS
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261QS0132X
TaxonomyOphthalmologic Surgery Clinic/Center
License Number0991AS
License Number StateOH

VIII. Authorized Official

Name: BRIAN R STAHL
Title or Position: MANAGING PARTNER/PRESIDENT
Credential: M.D.
Phone: 937-427-2020