Provider Demographics
NPI:1902307804
Name:WINE, CLARINDA YVETTE
Entity type:Individual
Prefix:
First Name:CLARINDA
Middle Name:YVETTE
Last Name:WINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 CANDLEWOOD PL
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-9661
Mailing Address - Country:US
Mailing Address - Phone:419-305-7283
Mailing Address - Fax:
Practice Address - Street 1:227 CANDLEWOOD PL
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-9661
Practice Address - Country:US
Practice Address - Phone:419-305-7283
Practice Address - Fax:877-283-0573
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-26
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.6317156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty