Provider Demographics
NPI:1104095454
Name:GAIL C HERRON JR
Entity type:Organization
Organization Name:GAIL C HERRON JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERRON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:330-332-8801
Mailing Address - Street 1:2400 SOUTHEAST BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-3481
Mailing Address - Country:US
Mailing Address - Phone:330-332-8801
Mailing Address - Fax:
Practice Address - Street 1:2400 SOUTHEAST BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-3481
Practice Address - Country:US
Practice Address - Phone:330-332-8801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2889/T1183152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0339824Medicaid
OH0339824Medicaid
OH0677620001Medicare NSC
OHHE0376802Medicare PIN