Healthcare Provider Details

I. General information

NPI: 1194340943
Provider Name (Legal Business Name): PRIMARY VISION CARE OF MOUNT VERNON INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4353 E STATE ROUTE 73
WAYNESVILLE OH
45068-8812
US

IV. Provider business mailing address

4353 E STATE ROUTE 73
WAYNESVILLE OH
45068-8812
US

V. Phone/Fax

Practice location:
  • Phone: 513-897-2211
  • Fax: 513-897-2213
Mailing address:
  • Phone: 513-897-2211
  • Fax: 513-897-2213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: MARK DAVID HENRY
Title or Position: OWNER
Credential:
Phone: 740-654-9909