=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831216605
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTI-VISION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5697 DARROW RD
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44236-4013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-650-0919
-----------------------------------------------------
Fax | 330-656-3151
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5697 DARROW RD
-----------------------------------------------------
City | HUDSON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44236-4013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-650-0919
-----------------------------------------------------
Fax | 330-656-3151
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | V.P.
-----------------------------------------------------
Name | MR. DAVE MUMICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 330-650-0919
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number | SC6292
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------