1780665059 NPI number — EYE CENTER GROUP LLC

Table of content: (NPI 1780665059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780665059 NPI number — EYE CENTER GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EYE CENTER GROUP 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:
1780665059
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 472
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNCIE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47308-0472
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-286-8888
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
375 TROJAN LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW CASTLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47362-2966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-521-0675
Provider Business Practice Location Address Fax Number:
765-593-0703
Provider Enumeration Date:
11/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
RAPKIN
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PART OWNER
Authorized Official Telephone Number:
765-286-8888

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2348267 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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