Provider Demographics
NPI:1124307004
Name:BUCKEYE OPTOMETRY
Entity type:Organization
Organization Name:BUCKEYE OPTOMETRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:BRUCH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-389-1300
Mailing Address - Street 1:150 MCMAHAN BLVD
Mailing Address - Street 2:BUCKEYE OPTICAL
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-5654
Mailing Address - Country:US
Mailing Address - Phone:740-389-1300
Mailing Address - Fax:740-389-1335
Practice Address - Street 1:150 MCMAHAN BLVD
Practice Address - Street 2:BUCKEYE OPTICAL
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-5654
Practice Address - Country:US
Practice Address - Phone:740-389-1300
Practice Address - Fax:740-389-1335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5096152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty