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General NPI Number Information
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NPI Number | 1104264431
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Entity Type | Organization
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Legal Business Name | IDEAL VISION LLC
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Dates
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Enumeration Date | 06/09/2013
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Last Update Date | 06/09/2013
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Provider Practice Location Address
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Address Line | 4474 EVERHARD RD NW
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City | CANTON
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State | OH
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Zip | 44718-2418
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Country | US
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Telephone | 330-494-4445
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Fax |
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Provider Business Mailing Address
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Address Line | 4474 EVERHARD RD NW
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City | CANTON
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State | OH
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Zip | 44718-2418
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Country | US
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Telephone | 330-494-4445
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | MRS. THERESA MARIE AYERS
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Credential |
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Telephone | 330-806-2312
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | S 4032
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License Number State | OH
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