Healthcare Provider Details

I. General information

NPI: 1932521580
Provider Name (Legal Business Name): PEAK VISUAL PERFORMANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 S SCATTERFIELD RD STE B
ANDERSON IN
46016-5788
US

IV. Provider business mailing address

1537 S SCATTERFIELD RD STE B
ANDERSON IN
46016-5766
US

V. Phone/Fax

Practice location:
  • Phone: 765-649-1200
  • Fax: 765-649-4040
Mailing address:
  • Phone: 765-649-1200
  • Fax: 765-649-4040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002944A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152WS0006X
TaxonomySports Vision Optometrist
License Number18002944A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number18002944A
License Number StateIN

VIII. Authorized Official

Name: DR. RAJENDER MACHA
Title or Position: PRESIDENT/OWNER
Credential: OD
Phone: 765-649-1200