Healthcare Provider Details

I. General information

NPI: 1619148145
Provider Name (Legal Business Name): CROSSTOWN EYECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2008
Last Update Date: 12/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 S MARION ST
MARTINSVILLE IN
46151-2438
US

IV. Provider business mailing address

990 S MARION ST
MARTINSVILLE IN
46151-2438
US

V. Phone/Fax

Practice location:
  • Phone: 765-342-5497
  • Fax: 765-349-1922
Mailing address:
  • Phone: 765-342-5497
  • Fax: 765-349-1922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001808B
License Number StateIN

VIII. Authorized Official

Name: DR. D. PENN MOODY
Title or Position: MEMBER
Credential: O.D.
Phone: 765-342-5497