Healthcare Provider Details

I. General information

NPI: 1649591082
Provider Name (Legal Business Name): SMOOT EYE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 05/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 K ST
BEDFORD IN
47421-3723
US

IV. Provider business mailing address

1515 K ST
BEDFORD IN
47421-3723
US

V. Phone/Fax

Practice location:
  • Phone: 812-675-4199
  • Fax: 812-675-0301
Mailing address:
  • Phone: 812-675-4199
  • Fax: 812-675-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003555A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number18003555A
License Number StateIN

VIII. Authorized Official

Name: DR. MICHELLE LYNN SMOOT
Title or Position: OPTOMETRIST
Credential: O.D.
Phone: 812-583-9203