=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831275882
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLOVERNOOK CENTER FOR THE BLIND AND VISUALLY IMPAIRED
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/31/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 368 BIELBY RD. SUITE #120
-----------------------------------------------------
City | LAWRENCEBURG
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47025-1199
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-537-0417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7000 HAMILTON AVE.
-----------------------------------------------------
City | CINCINNATI
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45231-5297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-522-3860
-----------------------------------------------------
Fax | 513-728-3946
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF PROGRAM SERVICES
-----------------------------------------------------
Name | MS. ROBIN LESLIE USALIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 513-522-3860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152WL0500X
-----------------------------------------------------
Taxonomy Name | Low Vision Rehabilitation Optometrist
-----------------------------------------------------
License Number | 35027971
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------