Healthcare Provider Details

I. General information

NPI: 1811150196
Provider Name (Legal Business Name): CROSS ROADS EYE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 SOUTH URBANA ST
SOUTH VIENNA OH
45369
US

IV. Provider business mailing address

PO BOX 190
SOUTH VIENNA OH
45369-0190
US

V. Phone/Fax

Practice location:
  • Phone: 740-506-2521
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5107
License Number StateOH

VIII. Authorized Official

Name: DR. KRISTEN M. THOMPSON
Title or Position: SOLE MEMBER, LLC
Credential: OD
Phone: 740-506-2521