MEDICARE: EYE SPECIALIST INC

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	152W00000X	Optometrist
2	207W00000X	Ophthalmology Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407805625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYE SPECIALIST INC

Provider Business Mailing Address
First Line	:	50 N PLAZA BLVD
Second Line	:
City	:	CHILLICOTHEE
State	:	OH
Zip	:	45601-1757
Country	:	US
Telephone Number	:	866-587-8790
Fax Number	:	740-774-4061

Provider Business Practice Location Address
First Line	:	3989 JACKPOT ROAD
Second Line	:
City	:	GROVE CITY
State	:	OH
Zip	:	43123-4835
Country	:	US
Telephone Number	:	614-801-9111
Fax Number	:	614-801-1643

Authorized Official
Title or Position	:	CENTER DIRECTOR
Name	:	TERRY SCHULTZ
Credential	:	OD
Telephone Number	:	800-948-3937

Provider Enumeration Date	:	05/06/2006
Last Update Date	:	09/15/2014

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Directions to “EYE SPECIALIST INC ” Practice Location

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