Basic Information
| Provider Information | |||||||||
| NPI: | 1043488778 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE CENTER GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MORRISON EYE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 472 | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473080472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652868888 | ||||||||
| FaxNumber: | 7657477962 | ||||||||
| Practice Location | |||||||||
| Address1: | 3631 N MORRISON RD | ||||||||
| Address2: | |||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473045547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652868888 | ||||||||
| FaxNumber: | 7657477962 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2008 | ||||||||
| LastUpdateDate: | 06/27/2008 | ||||||||
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| AuthorizedOfficialLastName: | WINCONEK | ||||||||
| AuthorizedOfficialFirstName: | DORIAN | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7652868888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 100339260S | 05 | IN | MEDICAID |