Healthcare Provider Details

I. General information

NPI: 1922104660
Provider Name (Legal Business Name): BALOG BREMEN VISION CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 W PLYMOUTH ST
BREMEN IN
46506-1951
US

IV. Provider business mailing address

1425 W PLYMOUTH ST
BREMEN IN
46506-1951
US

V. Phone/Fax

Practice location:
  • Phone: 574-546-3820
  • Fax: 574-546-3810
Mailing address:
  • Phone: 574-546-3820
  • Fax: 574-546-3810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001983A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number18001983A
License Number StateIN

VIII. Authorized Official

Name: DR. CAROLYN M BALOG
Title or Position: PRESIDENT
Credential: O.D.
Phone: 574-546-3820