Healthcare Provider Details

I. General information

NPI: 1568318897
Provider Name (Legal Business Name): BRIDGEPORT EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2026
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 3RD ST
BRIDGEPORT OH
43912-1605
US

IV. Provider business mailing address

100 3RD ST
BRIDGEPORT OH
43912-1605
US

V. Phone/Fax

Practice location:
  • Phone: 740-635-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State

VIII. Authorized Official

Name: LEON M FAVEDE
Title or Position: OWNER
Credential: OD
Phone: 740-359-5920