Healthcare Provider Details

I. General information

NPI: 1922525427
Provider Name (Legal Business Name): FAMILY FIRST VISION CARE INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6502 GRAPE RD
MISHAWAKA IN
46545-1102
US

IV. Provider business mailing address

4680 PARKWAY DR STE 455
MASON OH
45040-8199
US

V. Phone/Fax

Practice location:
  • Phone: 574-227-7723
  • Fax: 574-227-7723
Mailing address:
  • Phone: 513-445-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RYAN WILLIAMS
Title or Position: COO
Credential:
Phone: 904-545-4465