Healthcare Provider Details

I. General information

NPI: 1245476191
Provider Name (Legal Business Name): MODERN EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2008
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 E STATE ROUTE 613
CONTINENTAL OH
45831-9133
US

IV. Provider business mailing address

PO BOX 42
CONTINENTAL OH
45831-0042
US

V. Phone/Fax

Practice location:
  • Phone: 419-596-3062
  • Fax:
Mailing address:
  • Phone: 419-596-3062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JOY M ELLERBROCK
Title or Position: OWNER
Credential: O.D.
Phone: 419-615-3802