Healthcare Provider Details

I. General information

NPI: 1669692190
Provider Name (Legal Business Name): NORTHEAST OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 E 38TH ST
INDIANAPOLIS IN
46218-1229
US

IV. Provider business mailing address

2815 E 38TH ST
INDIANAPOLIS IN
46218-1229
US

V. Phone/Fax

Practice location:
  • Phone: 317-547-5525
  • Fax: 317-543-0948
Mailing address:
  • Phone: 317-547-5525
  • Fax: 317-543-0948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number01036129A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number01036129A
License Number StateIN

VIII. Authorized Official

Name: DR. LINDA FUNDENBERGER
Title or Position: OWNER
Credential: M.D.
Phone: 317-547-5525