MEDICARE: GRACE VISION, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	5016	OH

General Provider Information

NPI Number	:	1225461544
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE VISION, LLC

Provider Business Mailing Address
First Line	:	6007 WOODBROOK CT
Second Line	:
City	:	LEWIS CENTER
State	:	OH
Zip	:	43035-9240
Country	:	US
Telephone Number	:	614-946-8205
Fax Number	:

Provider Business Practice Location Address
First Line	:	2314 TAYLOR PARK DR
Second Line	:
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-8052
Country	:	US
Telephone Number	:	614-863-0071
Fax Number	:	614-856-0534

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DAWN LYNETTE HARTMAN
Credential	:	O.D.
Telephone Number	:	614-946-8205

Provider Enumeration Date	:	08/11/2013
Last Update Date	:	08/11/2013

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