Basic Information
| Provider Information | |||||||||
| NPI: | 1952439234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLOOMINGTON EYE CARE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474045227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123365432 | ||||||||
| FaxNumber: | 8123325084 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 W 3RD ST | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474045227 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123365432 | ||||||||
| FaxNumber: | 8123325084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | MCCALLA-JACKSON | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8123365432 | ||||||||
| 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 | 56000371A | IN | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
No ID Information.