Provider Demographics
NPI:1104264431
Name:IDEAL VISION LLC
Entity type:Organization
Organization Name:IDEAL VISION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:AYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-806-2312
Mailing Address - Street 1:4474 EVERHARD RD NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2418
Mailing Address - Country:US
Mailing Address - Phone:330-494-4445
Mailing Address - Fax:
Practice Address - Street 1:4474 EVERHARD RD NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2418
Practice Address - Country:US
Practice Address - Phone:330-494-4445
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-09
Last Update Date:2013-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS 4032332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier