Healthcare Provider Details

I. General information

NPI: 1598487423
Provider Name (Legal Business Name): PK OPTICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2022
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32313 VINE STREET
WILLOWICK OH
44095-3371
US

IV. Provider business mailing address

32313 VINE STREET
WILLOWICK OH
44095-3371
US

V. Phone/Fax

Practice location:
  • Phone: 440-943-6858
  • Fax: 440-943-4082
Mailing address:
  • Phone: 440-943-6858
  • Fax: 440-943-4082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: MR. PHILLIP A BASILE
Title or Position: OPTICIAN
Credential: OPTICIAN
Phone: 440-943-6858