=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699822627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMPUS OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4729 REED ROAD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-326-2020
-----------------------------------------------------
Fax | 614-457-9767
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4729 REED ROAD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-326-2020
-----------------------------------------------------
Fax | 614-457-9767
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER OPTICIAN
-----------------------------------------------------
Name | MRS. STEPHANIE L PLASSE
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 614-326-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OH4703
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OH3977
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------