Provider Demographics
NPI:1780806067
Name:EYE SITE, L.L.C.
Entity type:Organization
Organization Name:EYE SITE, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:DIETZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-467-2525
Mailing Address - Street 1:12464 LANCASTER ST
Mailing Address - Street 2:PO BOX 421
Mailing Address - City:MILLERSPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43046-9787
Mailing Address - Country:US
Mailing Address - Phone:740-467-2525
Mailing Address - Fax:740-467-3015
Practice Address - Street 1:12464 LANCASTER ST
Practice Address - Street 2:
Practice Address - City:MILLERSPORT
Practice Address - State:OH
Practice Address - Zip Code:43046-9787
Practice Address - Country:US
Practice Address - Phone:740-467-2525
Practice Address - Fax:740-467-3015
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE EYE SITE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0294346Medicaid
OH2235414Medicaid
4029154Medicare PIN
1780806067Medicare PIN
OH2235414Medicaid
9316052Medicare PIN
0816925Medicare PIN
1356441802Medicare PIN
U81255Medicare UPIN
1205926318Medicare PIN