Provider Demographics
NPI:1306061379
Name:NORTHSIDE OPTICAL LLC
Entity type:Organization
Organization Name:NORTHSIDE OPTICAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSED OPTICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:PEGGY
Authorized Official - Middle Name:LOU
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSED OPTICIAN
Authorized Official - Phone:937-472-3366
Mailing Address - Street 1:140 NORTH BARRON ST
Mailing Address - Street 2:
Mailing Address - City:EATON
Mailing Address - State:OH
Mailing Address - Zip Code:45320
Mailing Address - Country:US
Mailing Address - Phone:937-472-3937
Mailing Address - Fax:937-472-3937
Practice Address - Street 1:140 NORTH BARRON ST
Practice Address - Street 2:
Practice Address - City:EATON
Practice Address - State:OH
Practice Address - Zip Code:45320
Practice Address - Country:US
Practice Address - Phone:937-472-3937
Practice Address - Fax:937-472-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSC2262156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2618359Medicaid