Provider Demographics
NPI:1679763577
Name:PICKERINGTON EYECARE
Entity type:Organization
Organization Name:PICKERINGTON EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:TRACY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:614-575-0111
Mailing Address - Street 1:141 CLINT DRIVE
Mailing Address - Street 2:
Mailing Address - City:PICKERINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43147
Mailing Address - Country:US
Mailing Address - Phone:614-575-0111
Mailing Address - Fax:614-577-9214
Practice Address - Street 1:141 CLINT DRIVE
Practice Address - Street 2:
Practice Address - City:PICKERINGTON
Practice Address - State:OH
Practice Address - Zip Code:43147
Practice Address - Country:US
Practice Address - Phone:614-575-0111
Practice Address - Fax:614-577-9214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4686152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
9341681Medicare PIN
OHU80888Medicare UPIN
OH6101210001Medicare NSC
OHT69293Medicare UPIN