Provider Demographics
NPI:1992316848
Name:VISION SOURCE MARYSVILLE
Entity type:Organization
Organization Name:VISION SOURCE MARYSVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MALLORIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-644-8637
Mailing Address - Street 1:303 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1113
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1113
Practice Address - Country:US
Practice Address - Phone:937-644-2075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COURTNEY L POLING OD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-13
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty