1700971686 NPI number — PROFESSIONAL VISION INC

Table of content: (NPI 1700971686)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700971686 NPI number — PROFESSIONAL VISION INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL VISION INC
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:
1700971686
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17615 STATE ROAD 23
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1718
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-234-7600
Provider Business Mailing Address Fax Number:
574-234-8408

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4630 W WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46619-2304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-287-5949
Provider Business Practice Location Address Fax Number:
574-287-6068
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SNYDER
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER-PRESIDENT
Authorized Official Telephone Number:
574-234-7600

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18001393 , 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: 000000105031 . This is a "ANTHEM" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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