Healthcare Provider Details

I. General information

NPI: 1427748243
Provider Name (Legal Business Name): MADISON EYE CARE OF PORT CLINTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/15/2023
Certification Date: 05/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 JEFFERSON ST
PORT CLINTON OH
43452-2416
US

IV. Provider business mailing address

26927 DETROIT RD
WESTLAKE OH
44145-2370
US

V. Phone/Fax

Practice location:
  • Phone: 419-732-2828
  • Fax:
Mailing address:
  • Phone: 440-892-5367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. KYLE KOUBEK
Title or Position: DOCTOR/PART OWNER
Credential: OD
Phone: 440-892-5367