Healthcare Provider Details

I. General information

NPI: 1194099093
Provider Name (Legal Business Name): PARTNERS OPTICAL SUPPLY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2012
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 E MAIN ST
RAVENNA OH
44266-3128
US

IV. Provider business mailing address

159 E MAIN ST
RAVENNA OH
44266-3128
US

V. Phone/Fax

Practice location:
  • Phone: 330-297-7733
  • Fax: 330-297-0170
Mailing address:
  • Phone: 330-297-7733
  • Fax: 330-297-0170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3555 T1593
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3555 T1593
License Number StateOH

VIII. Authorized Official

Name: AARON ALVIE MOATS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 330-297-7733