Healthcare Provider Details

I. General information

NPI: 1104608348
Provider Name (Legal Business Name): REVOLUTIONEYES 2 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11464 LAKERIDGE DR
FISHERS IN
46037-7607
US

IV. Provider business mailing address

11464 LAKERIDGE DR
FISHERS IN
46037-7607
US

V. Phone/Fax

Practice location:
  • Phone: 317-790-2015
  • Fax: 317-708-7324
Mailing address:
  • Phone: 317-790-2015
  • Fax: 317-708-7324

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY DRAHEIM
Title or Position: PRACTICE MANAGER
Credential:
Phone: 317-790-2015