Healthcare Provider Details

I. General information

NPI: 1205974516
Provider Name (Legal Business Name): TRI STATE OCULAR PROSTHETICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 07/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 TRI COUNTY PKWY SUITE 201
CINCINNATI OH
45246-3289
US

IV. Provider business mailing address

130 TRI COUNTY PKWY SUITE 201
CINCINNATI OH
45246-3289
US

V. Phone/Fax

Practice location:
  • Phone: 513-771-6029
  • Fax: 513-771-6187
Mailing address:
  • Phone: 513-771-6029
  • Fax: 513-771-6187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License NumberO.11
License Number StateOH

VIII. Authorized Official

Name: ANDREW W HETZLER
Title or Position: PRESIDENT
Credential: B.C.O., B.A.D.O.
Phone: 513-310-2060