Healthcare Provider Details

I. General information

NPI: 1891778098
Provider Name (Legal Business Name): FAMILY EYE CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 02/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 FOREST PARK DR
BERNE IN
46711-1745
US

IV. Provider business mailing address

150 FOREST PARK DRIVE P.O. BOX 30
BERNE IN
46711-0030
US

V. Phone/Fax

Practice location:
  • Phone: 260-589-3197
  • Fax: 260-589-2911
Mailing address:
  • Phone: 260-589-3197
  • Fax: 260-589-2911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18002194B
License Number StateIN

VIII. Authorized Official

Name: STEVEN A. DEGROFF
Title or Position: PRESIDENT
Credential: O.D.
Phone: 260-589-3197