1619148145 NPI number — CROSSTOWN EYECARE LLC

Table of content: (NPI 1619148145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619148145 NPI number — CROSSTOWN EYECARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSTOWN EYECARE 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:
1619148145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
990 S MARION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARTINSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46151-2438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-342-5497
Provider Business Mailing Address Fax Number:
765-349-1922

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
990 S MARION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARTINSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46151-2438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-342-5497
Provider Business Practice Location Address Fax Number:
765-349-1922
Provider Enumeration Date:
03/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MOODY
Authorized Official First Name:
D.
Authorized Official Middle Name:
PENN
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
765-342-5497

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18001808B , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 02875 . This is a "SPECTERA" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: IN1808 . This is a "EYEMED" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 4434 . This is a "DAVIS VISION" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 23091 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7653425497 . This is a "VISION SERVICE PLAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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