Healthcare Provider Details

I. General information

NPI: 1306091574
Provider Name (Legal Business Name): MICHAEL L. RECKER, O.D. LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2008
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 LOUISIANA AVE
PERRYSBURG OH
43551-2269
US

IV. Provider business mailing address

410 LOUISIANA AVE
PERRYSBURG OH
43551-2269
US

V. Phone/Fax

Practice location:
  • Phone: 419-872-2020
  • Fax: 419-872-2029
Mailing address:
  • Phone: 419-872-2020
  • Fax: 419-872-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4870
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number4870
License Number StateOH

VIII. Authorized Official

Name: MRS. JODI M. RECKER
Title or Position: BUSINESS MANAGER
Credential:
Phone: 419-872-2020