1710997044 NPI number — INDIANA VISION CLINIC, INC

Table of content: (NPI 1710997044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710997044 NPI number — INDIANA VISION CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA VISION CLINIC, 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:
1710997044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2730A CASSOPOLIS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELKHART
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46514-5102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-266-5470
Provider Business Mailing Address Fax Number:
574-264-3081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2730A CASSOPOLIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELKHART
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46514-5102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-266-5470
Provider Business Practice Location Address Fax Number:
574-264-3081
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILOVICH
Authorized Official First Name:
RONALD
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
574-266-5470

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18001593A , 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: 000000273028 . This is a "BCBS ELKHART GROUP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200380990B , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2550910002 . This is a "DURABLE MEDICAL EQUIP" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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