Basic Information
Provider Information | |||||||||
NPI: | 1306197223 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EYECARE INDIANA II, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | C&B OPTICAL ONE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4121 S MICHIGAN ST | ||||||||
Address2: |   | ||||||||
City: | SOUTH BEND | ||||||||
State: | IN | ||||||||
PostalCode: | 466142545 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742919200 | ||||||||
FaxNumber: | 5742994423 | ||||||||
Practice Location | |||||||||
Address1: | 12479 STATE ROAD 23 | ||||||||
Address2: | SUITE E | ||||||||
City: | GRANGER | ||||||||
State: | IN | ||||||||
PostalCode: | 465308040 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5742773077 | ||||||||
FaxNumber: | 5742773288 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/02/2012 | ||||||||
LastUpdateDate: | 11/16/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PESCHKE | ||||||||
AuthorizedOfficialFirstName: | TERRI | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 5742919200 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |   |
No ID Information.