Healthcare Provider Details

I. General information

NPI: 1639204720
Provider Name (Legal Business Name): VIRTUAL IMAGE EYEWEAR PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 04/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 E 82ND ST STE 2300
INDIANAPOLIS IN
46250
US

IV. Provider business mailing address

10610 N PENNSYLVANIA ST STE B
INDIANAPOLIS IN
46280-2000
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-6269
  • Fax: 317-815-7567
Mailing address:
  • Phone: 317-844-6269
  • Fax: 317-815-7567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0111609909
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0111609909
License Number StateIN

VIII. Authorized Official

Name: DR. EARL E LANTER
Title or Position: PRESEIDENT
Credential: M.D. O.D.
Phone: 317-844-6269