Healthcare Provider Details

I. General information

NPI: 1659401180
Provider Name (Legal Business Name): DR PATRICK HENRY OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 WEST WAYNE ST
MAUMEE OH
43537-2150
US

IV. Provider business mailing address

109 WEST WAYNE ST
MAUMEE OH
43537-2150
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-6841
  • Fax: 419-893-4894
Mailing address:
  • Phone: 419-893-6841
  • Fax: 419-893-4894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number5163 T2062
License Number StateOH

VIII. Authorized Official

Name: MRS. HOPE D WCISLAK
Title or Position: BILLING MANAGER
Credential:
Phone: 419-893-6841