Basic Information
| Provider Information | |||||||||
| NPI: | 1477735538 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYES ON MAIN, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 334 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458403353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194222015 | ||||||||
| FaxNumber: | 4194279477 | ||||||||
| Practice Location | |||||||||
| Address1: | 334 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FINDLAY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458403353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194222015 | ||||||||
| FaxNumber: | 4194279477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2007 | ||||||||
| LastUpdateDate: | 01/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WIRES | ||||||||
| AuthorizedOfficialFirstName: | DUANE | ||||||||
| AuthorizedOfficialMiddleName: | LESLIE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4194222015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | O.D. | ||||||||
| NPICertificationDate: | 01/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 3756T705 | OH | N | Suppliers | Durable Medical Equipment & Medical Supplies | 152W00000X | 3756T705 | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 055775 | 05 | OH | MEDICAID |