Healthcare Provider Details

I. General information

NPI: 1689643520
Provider Name (Legal Business Name): NEIL A. PENCE O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 E 3RD ST
BLOOMINGTON IN
47405-3603
US

IV. Provider business mailing address

800 E ATWATER AVE FL 2
BLOOMINGTON IN
47405-3635
US

V. Phone/Fax

Practice location:
  • Phone: 812-855-8436
  • Fax: 812-855-1683
Mailing address:
  • Phone: 812-855-8436
  • Fax: 812-855-6116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001900
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: