Healthcare Provider Details

I. General information

NPI: 1164642435
Provider Name (Legal Business Name): DR PATRICK HENRY OD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2007
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6790 PROVIDENCE ST
WHITEHOUSE OH
43571
US

IV. Provider business mailing address

109 W WAYNE ST
MAUMEE OH
43537-2150
US

V. Phone/Fax

Practice location:
  • Phone: 419-877-1188
  • Fax: 419-877-1156
Mailing address:
  • Phone: 419-893-6841
  • Fax: 419-893-4894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOH5163
License Number StateOH

VIII. Authorized Official

Name: MRS. HOPE D WCISLAK
Title or Position: BILLING MANAGER
Credential:
Phone: 419-824-3318