1649591082 NPI number — SMOOT EYE CARE, LLC

Table of content: (NPI 1649591082)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649591082 NPI number — SMOOT EYE CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMOOT EYE CARE, 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:
1649591082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 K ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEDFORD
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47421-3723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-675-4199
Provider Business Mailing Address Fax Number:
812-675-0301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1515 K ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEDFORD
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47421-3723
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-675-4199
Provider Business Practice Location Address Fax Number:
812-675-0301
Provider Enumeration Date:
06/21/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SMOOT
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OPTOMETRIST
Authorized Official Telephone Number:
812-583-9203

Provider Taxonomy Codes

  • Taxonomy code: 152WP0200X , with the licence number:  18003555A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 18003555A , 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: 200985290A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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