Provider Demographics
NPI:1265148522
Name:MODERN HERITAGE EYE CARE, LLC
Entity type:Organization
Organization Name:MODERN HERITAGE EYE CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAHRAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHASTEEN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-873-7446
Mailing Address - Street 1:5150 CHAPPEL DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-7256
Mailing Address - Country:US
Mailing Address - Phone:419-873-7446
Mailing Address - Fax:
Practice Address - Street 1:5150 CHAPPEL DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-7256
Practice Address - Country:US
Practice Address - Phone:419-873-7446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-30
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty