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General NPI Number Information
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NPI Number | 1205974516
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Entity Type | Organization
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Legal Business Name | TRI STATE OCULAR PROSTHETICS, LLC
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Dates
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Enumeration Date | 02/01/2007
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Last Update Date | 07/11/2016
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Provider Practice Location Address
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Address Line | 130 TRI COUNTY PKWY SUITE 201
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City | CINCINNATI
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State | OH
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Zip | 45246-3289
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Country | US
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Telephone | 513-771-6029
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Fax | 513-771-6187
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Provider Business Mailing Address
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Address Line | 130 TRI COUNTY PKWY SUITE 201
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City | CINCINNATI
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State | OH
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Zip | 45246-3289
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Country | US
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Telephone | 513-771-6029
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Fax | 513-771-6187
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Authorized Official
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Title or Position | PRESIDENT
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Name | ANDREW W HETZLER
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Credential | B.C.O., B.A.D.O.
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Telephone | 513-310-2060
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 156FX1700X
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Taxonomy Name | Ocularist
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License Number | O.11
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License Number State | OH
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