Healthcare Provider Details

I. General information

NPI: 1316004187
Provider Name (Legal Business Name): NORTHWEST OPTOMETRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 10/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

639 W NATIONAL RD
ENGLEWOOD OH
45322-1155
US

IV. Provider business mailing address

639 W NATIONAL RD
ENGLEWOOD OH
45322-1155
US

V. Phone/Fax

Practice location:
  • Phone: 937-836-3041
  • Fax: 937-836-1937
Mailing address:
  • Phone: 937-836-3041
  • Fax: 937-836-1937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3970
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number3970
License Number StateOH

VIII. Authorized Official

Name: DR. JOSEPH STUDEBAKER
Title or Position: PARTNER
Credential: O.D.
Phone: 937-836-3041