Healthcare Provider Details

I. General information

NPI: 1578760468
Provider Name (Legal Business Name): DISTINCTIVE EYEWEAR INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2007
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5690 WALLINGS RD
NORTH ROYALTON OH
44133-3044
US

IV. Provider business mailing address

5690 WALLINGS RD
NORTH ROYALTON OH
44133-3044
US

V. Phone/Fax

Practice location:
  • Phone: 440-877-2020
  • Fax: 440-877-9531
Mailing address:
  • Phone: 440-877-2020
  • Fax: 440-877-9531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5054
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number StateOH

VIII. Authorized Official

Name: DR. JENNIFER LYNN MENTESSI
Title or Position: PRESIDENT
Credential: O.D.
Phone: 440-877-2020