=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043406721
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. RONALD L. DETWILER, O.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2007
-----------------------------------------------------
Last Update Date | 11/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15655 STATE RT 170 SUITE C
-----------------------------------------------------
City | EAST LIVERPOOL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43920-9069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-385-3898
-----------------------------------------------------
Fax | 330-385-5772
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15655 STATE ROUTE 170 SUITE C
-----------------------------------------------------
City | EAST LIVERPOOL
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43920-9069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-385-3898
-----------------------------------------------------
Fax | 330-385-5772
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. RONALD L DETWILER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-385-3898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 3166 T1622
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------