1568630325 NPI number — LAFAYETTE RETINA CLINIC PC

Table of content: (NPI 1568630325)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568630325 NPI number — LAFAYETTE RETINA CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAFAYETTE RETINA CLINIC PC
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:
1568630325
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 PROFESSIONAL CT
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47905-5161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-446-9446
Provider Business Mailing Address Fax Number:
765-447-9672

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 PROFESSIONAL CT
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-5161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-446-9446
Provider Business Practice Location Address Fax Number:
765-447-9672
Provider Enumeration Date:
02/14/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SCHRAUT
Authorized Official First Name:
GARY
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
765-446-9446

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  01042571 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1C18940 . This is a "LEGACY" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".