Healthcare Provider Details

I. General information

NPI: 1710150347
Provider Name (Legal Business Name): POWELL VISION CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2008
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 NAVARRE AVE
OREGON OH
43616-3437
US

IV. Provider business mailing address

3975 NAVARRE AVE
OREGON OH
43616-3437
US

V. Phone/Fax

Practice location:
  • Phone: 419-698-4949
  • Fax: 419-698-9948
Mailing address:
  • Phone: 419-698-4949
  • Fax: 419-698-9948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. BLAKE G. POWELL
Title or Position: OWNER
Credential: O.D.
Phone: 419-698-4949