1083890172 NPI number — SUPERIOR VISION, LLC

Table of content: (NPI 1083890172)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083890172 NPI number — SUPERIOR VISION, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR VISION, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083890172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8190 WINDFALL LN
Provider Second Line Business Mailing Address:
STE C
Provider Business Mailing Address City Name:
CAMBY
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46113-7906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-856-2000
Provider Business Mailing Address Fax Number:
317-865-2000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10922 E COUNTY ROAD 800 S STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBY
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46113-9161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-856-2000
Provider Business Practice Location Address Fax Number:
317-865-2000
Provider Enumeration Date:
01/18/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PORTER
Authorized Official First Name:
DIANNE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
O.D./PRESIDENT
Authorized Official Telephone Number:
812-320-4362

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  18002637B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200893590 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".