1639238165 NPI number — MATTINGLY CENTER FOR SIGHT LLC

Table of content: (NPI 1639238165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639238165 NPI number — MATTINGLY CENTER FOR SIGHT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MATTINGLY CENTER FOR SIGHT 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:
1639238165
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1410 UNION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47904-2060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-423-2977
Provider Business Mailing Address Fax Number:
765-423-1149

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1410 UNION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47904-2060
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-423-2977
Provider Business Practice Location Address Fax Number:
765-423-1149
Provider Enumeration Date:
12/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MATTINGLY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
OWNER-PHYSICIAN
Authorized Official Telephone Number:
765-423-2977

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  01026310A , 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: 351654025 . This is a "SAGAMORE HEALTH NETWORK" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 000000086144 . This is a "BCBS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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