Provider Demographics
NPI:1730204694
Name:PROFESSIONAL VISIONCARE, INC.
Entity type:Organization
Organization Name:PROFESSIONAL VISIONCARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLOGGI
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-898-9989
Mailing Address - Street 1:185 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2232
Mailing Address - Country:US
Mailing Address - Phone:614-898-9989
Mailing Address - Fax:614-898-3054
Practice Address - Street 1:185 S STATE ST
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-2232
Practice Address - Country:US
Practice Address - Phone:614-898-9989
Practice Address - Fax:614-898-3054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2507666Medicaid
OH0603670001Medicare NSC
OH9250791Medicare PIN