1063097533 NPI number — MYEYEDR OPTOMETRY OF INDIANA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063097533 NPI number — MYEYEDR OPTOMETRY OF INDIANA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYEYEDR OPTOMETRY OF INDIANA, 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:
6
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:
1063097533
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8614 WESTWOOD CENTER DR FL 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIENNA
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22182-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-847-8899
Provider Business Mailing Address Fax Number:
571-223-6780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 N WAYNE ST STE F
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGOLA
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46703-2359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-668-8881
Provider Business Practice Location Address Fax Number:
260-665-6498
Provider Enumeration Date:
03/16/2021

Additional Information

Authorized Official

Authorized Official Last Name:
DOWNES
Authorized Official First Name:
SUE
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
703-847-8899

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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