Healthcare Provider Details

I. General information

NPI: 1609914829
Provider Name (Legal Business Name): RGM OPTICAL SRV INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6079 BRANDT PIKE
HUBER HEIGHTS OH
45424
US

IV. Provider business mailing address

6079 BRANDT PIKE
HUBER HEIGHTS OH
45424
US

V. Phone/Fax

Practice location:
  • Phone: 937-237-8669
  • Fax: 937-237-9019
Mailing address:
  • Phone: 937-237-8669
  • Fax: 937-237-9019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4554
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberS5371
License Number StateOH

VIII. Authorized Official

Name: MR. REY G MALONJAO
Title or Position: PRESIDENT LDO
Credential: LICENSING DISPENSING
Phone: 937-237-8669