Provider Demographics
NPI:1801104260
Name:COSHOCTON VISION CENTER, LLC
Entity type:Organization
Organization Name:COSHOCTON VISION CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FORNARA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-622-1484
Mailing Address - Street 1:95 W DAVE LONGABERGER AVE
Mailing Address - Street 2:
Mailing Address - City:DRESDEN
Mailing Address - State:OH
Mailing Address - Zip Code:43821-9687
Mailing Address - Country:US
Mailing Address - Phone:740-754-3800
Mailing Address - Fax:740-754-2050
Practice Address - Street 1:95 W DAVE LONGABERGER AVE
Practice Address - Street 2:
Practice Address - City:DRESDEN
Practice Address - State:OH
Practice Address - Zip Code:43821-9687
Practice Address - Country:US
Practice Address - Phone:740-754-3800
Practice Address - Fax:740-754-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-20
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5622152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0099076Medicaid
OH2873832Medicaid
OH5810490002Medicare NSC
OHCO9363991Medicare PIN