Provider Demographics
NPI:1548443302
Name:CHAGRIN VALLEY OPTOMETRISTS, INC
Entity type:Organization
Organization Name:CHAGRIN VALLEY OPTOMETRISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:JURCAK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:440-338-5900
Mailing Address - Street 1:5210 CHILLICOTHE RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-4300
Mailing Address - Country:US
Mailing Address - Phone:440-338-5900
Mailing Address - Fax:440-338-1024
Practice Address - Street 1:5210 CHILLICOTHE RD STE B
Practice Address - Street 2:
Practice Address - City:CHAGRIN FALLS
Practice Address - State:OH
Practice Address - Zip Code:44022-4300
Practice Address - Country:US
Practice Address - Phone:440-338-5900
Practice Address - Fax:440-338-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3865152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000228073OtherANTHEM
OH2529900OtherUNTED HEALTHCARE
OH000000228073OtherANTHEM
OH0164210001Medicare NSC
OHT96113Medicare UPIN