=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770741092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK CENTRE OPTICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2008
-----------------------------------------------------
Last Update Date | 05/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 PARK CENTER DR SUITE 101
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-7100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-335-3881
-----------------------------------------------------
Fax | 330-334-9085
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 PARK CENTER DR SUITE 101
-----------------------------------------------------
City | WADSWORTH
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44281-7100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-335-3881
-----------------------------------------------------
Fax | 330-334-9085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER/OWNER
-----------------------------------------------------
Name | MS. ELAINE R NOE
-----------------------------------------------------
Credential | OPTICIAN
-----------------------------------------------------
Telephone | 330-335-3881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | S2805
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------