Basic Information
| Provider Information | |||||||||
| NPI: | 1811179112 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EYE CENTER GROUP LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KOKOMO 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: | 2302 S DIXON RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | KOKOMO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469026424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654533937 | ||||||||
| FaxNumber: | 7654558750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2007 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
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| AuthorizedOfficialLastName: | RAPKIN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PART-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7652868888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.