Provider Demographics
NPI:1427748243
Name:MADISON EYE CARE OF PORT CLINTON LLC
Entity type:Organization
Organization Name:MADISON EYE CARE OF PORT CLINTON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/PART OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUBEK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-892-5367
Mailing Address - Street 1:26927 DETROIT RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2370
Mailing Address - Country:US
Mailing Address - Phone:440-892-5367
Mailing Address - Fax:
Practice Address - Street 1:820 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2416
Practice Address - Country:US
Practice Address - Phone:419-732-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty