Healthcare Provider Details

I. General information

NPI: 1518139385
Provider Name (Legal Business Name): SPRINGFIELD EYE GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1674 NORTH LIMESTONE ST
SPRINGFIELD OH
45503
US

IV. Provider business mailing address

1674 N LIMESTONE ST
SPRINGFIELD OH
45503-2652
US

V. Phone/Fax

Practice location:
  • Phone: 937-399-4101
  • Fax: 937-399-2346
Mailing address:
  • Phone: 937-399-4101
  • Fax: 937-399-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4831
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number4831
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number4831
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code152WX0102X
TaxonomyOccupational Vision Optometrist
License Number4831
License Number StateOH

VIII. Authorized Official

Name: SARAH ELIZABETH ROGERS
Title or Position: ADMINISTRATOR
Credential:
Phone: 937-399-4101