Provider Demographics
NPI:1568673119
Name:SPEEDWAY OPTICAL
Entity type:Organization
Organization Name:SPEEDWAY OPTICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HARRISON
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:317-243-7397
Mailing Address - Street 1:1602 CUNNINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:SPEEDWAY
Mailing Address - State:IN
Mailing Address - Zip Code:46224
Mailing Address - Country:US
Mailing Address - Phone:317-243-7397
Mailing Address - Fax:317-247-1442
Practice Address - Street 1:1602 CUNNINGHAM DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224
Practice Address - Country:US
Practice Address - Phone:317-243-7397
Practice Address - Fax:317-247-1442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0002331748332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4111750001Medicare PIN