Healthcare Provider Details

I. General information

NPI: 1275813685
Provider Name (Legal Business Name): WADSWORTH EYE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2011
Last Update Date: 08/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 WADSWORTH RD SUITE 304
WADSWORTH OH
44281-9504
US

IV. Provider business mailing address

195 WADSWORTH RD SUITE 304
WADSWORTH OH
44281-9504
US

V. Phone/Fax

Practice location:
  • Phone: 330-247-2480
  • Fax: 330-336-0099
Mailing address:
  • Phone: 330-247-2480
  • Fax: 330-336-0099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5652
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35085999
License Number StateOH

VIII. Authorized Official

Name: ANDREA LOMBARDO
Title or Position: CLINICAL MANAGER
Credential:
Phone: 330-247-2480