Healthcare Provider Details

I. General information

NPI: 1366224057
Provider Name (Legal Business Name): PDR MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9330 BUCKBOARD DR
WASHINGTON TOWNSHIP OH
45458-3796
US

IV. Provider business mailing address

9330 BUCKBOARD DR
WASHINGTON TOWNSHIP OH
45458-3796
US

V. Phone/Fax

Practice location:
  • Phone: 260-402-1290
  • Fax:
Mailing address:
  • Phone: 260-402-1290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: AMANDA BELOTE
Title or Position: CONSULTANT
Credential:
Phone: 260-437-3970