Provider Demographics
NPI:1285679761
Name:VANDALIA OPTOMETRY LLC
Entity type:Organization
Organization Name:VANDALIA OPTOMETRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-898-3641
Mailing Address - Street 1:33 ELVA CT
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:OH
Mailing Address - Zip Code:45377-1828
Mailing Address - Country:US
Mailing Address - Phone:937-898-3641
Mailing Address - Fax:937-898-4322
Practice Address - Street 1:33 ELVA CT
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:OH
Practice Address - Zip Code:45377-1828
Practice Address - Country:US
Practice Address - Phone:937-898-3641
Practice Address - Fax:937-898-4322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4638152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHVO2509379Medicaid
OH5871690001Medicare NSC
OHVA9358601Medicare PIN