Basic Information
| Provider Information | |||||||||
| NPI: | 1245305143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMITH-BRIDENSTINE MK CO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SMITH-BRIDENSTINE FAMILY EYE CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6418 LANDBOROUGH SOUTH DR | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462204357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178451305 | ||||||||
| FaxNumber: | 3178451372 | ||||||||
| Practice Location | |||||||||
| Address1: | 9007 E 17TH ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462292016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178451305 | ||||||||
| FaxNumber: | 3178451372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 05/16/2009 | ||||||||
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| AuthorizedOfficialLastName: | MCCORD | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | SHAREHOLDER | ||||||||
| AuthorizedOfficialTelephone: | 3178451305 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332H00000X | Y | Suppliers | Eyewear Supplier (Equipment, not the service) |
No ID Information.