1821059320 NPI number — INDIANA VISION DEVELOPMENT CENTER PC

Table of content: (NPI 1821059320)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821059320 NPI number — INDIANA VISION DEVELOPMENT CENTER PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDIANA VISION DEVELOPMENT CENTER PC
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:
1821059320
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10343 DAWSONS CREEK BLVD
Provider Second Line Business Mailing Address:
STE B BLDG 6
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46825-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-497-7973
Provider Business Mailing Address Fax Number:
260-497-7986

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10343 DAWSONS CREEK BLVD
Provider Second Line Business Practice Location Address:
STE B BLDG 6
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-497-7973
Provider Business Practice Location Address Fax Number:
260-497-7986
Provider Enumeration Date:
04/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
CARL
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
260-497-7973

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  18002177A , 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: 200427750A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5544260001 . This is a "DMEPOS" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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