Basic Information
| Provider Information | |||||||||
| NPI: | 1003851445 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOLING VISION CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2746 OLD US 20 W | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742933545 | ||||||||
| FaxNumber: | 5745220599 | ||||||||
| Practice Location | |||||||||
| Address1: | 2746 OLD US 20 W | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742933545 | ||||||||
| FaxNumber: | 5745220599 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 03/05/2008 | ||||||||
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| AuthorizedOfficialLastName: | BOLING | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5742933545 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | II | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | DF9809 | 01 | RAILROAD MEDICARE | OTHER | C15688 | 01 | RAILROAD MEDICARE | OTHER |