Basic Information
| Provider Information | |||||||||
| NPI: | 1912098229 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL VISION INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17615 STATE ROAD 23 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742347600 | ||||||||
| FaxNumber: | 5742348408 | ||||||||
| Practice Location | |||||||||
| Address1: | 17615 STATE ROAD 23 | ||||||||
| Address2: | |||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742347600 | ||||||||
| FaxNumber: | 5742348408 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SNYDER | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER-PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5742347600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | OD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18001393 | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000000105030 | 01 | IN | ANTHEM | OTHER |