Provider Demographics
NPI:1386910511
Name:EYECARE INDIANA LL, PC
Entity type:Organization
Organization Name:EYECARE INDIANA LL, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:C.O.O.
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:PESCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-291-9200
Mailing Address - Street 1:4121 S. MICHIGAN STREET
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2545
Mailing Address - Country:US
Mailing Address - Phone:574-291-9200
Mailing Address - Fax:574-299-4423
Practice Address - Street 1:12479 STATE ROAD 23
Practice Address - Street 2:SUITE E
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8040
Practice Address - Country:US
Practice Address - Phone:574-277-3077
Practice Address - Fax:574-277-3288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty