Provider Demographics
NPI:1730378373
Name:VILLAGE VISION CENTER, INC.
Entity type:Organization
Organization Name:VILLAGE VISION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:WIRES
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:419-634-2921
Mailing Address - Street 1:107 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OH
Mailing Address - Zip Code:45810-1240
Mailing Address - Country:US
Mailing Address - Phone:419-634-2921
Mailing Address - Fax:419-634-9858
Practice Address - Street 1:107 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OH
Practice Address - Zip Code:45810-1240
Practice Address - Country:US
Practice Address - Phone:419-634-2921
Practice Address - Fax:419-634-9858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3756T705152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH055775Medicaid
OH0436130001Medicare NSC
OH055775Medicaid