Healthcare Provider Details

I. General information

NPI: 1932861713
Provider Name (Legal Business Name): UNIVERSITY PARK VISION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2021
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 MEDICAL PARK DR
FORT WAYNE IN
46825-5887
US

IV. Provider business mailing address

10723 KNOLLTON RUN
FORT WAYNE IN
46818-8746
US

V. Phone/Fax

Practice location:
  • Phone: 260-471-2000
  • Fax: 260-471-2100
Mailing address:
  • Phone: 260-705-2285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. AMY REIDHAAR
Title or Position: OPTOMETRIST
Credential: OD
Phone: 260-471-2000