Healthcare Provider Details

I. General information

NPI: 1992984033
Provider Name (Legal Business Name): EYES 20/20
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2007
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W BROAD ST SUITE A
NEWTON FALLS OH
44444-1572
US

IV. Provider business mailing address

115 W BROAD ST SUITE A
NEWTON FALLS OH
44444-1572
US

V. Phone/Fax

Practice location:
  • Phone: 330-872-1371
  • Fax:
Mailing address:
  • Phone: 330-872-1371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3576
License Number StateOH

VIII. Authorized Official

Name: DR. RONALD WALLIE
Title or Position: OWNER
Credential: OD
Phone: 330-872-1371