Healthcare Provider Details

I. General information

NPI: 1104815604
Provider Name (Legal Business Name): CITY OPTICAL CO., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 01/25/2023
Certification Date: 01/25/2023
Deactivation Date: 07/01/2015
Reactivation Date: 07/13/2015

III. Provider practice location address

4523 NATIONAL RD E
RICHMOND IN
47374-3731
US

IV. Provider business mailing address

2839 LAFAYETTE ROAD
INDIANAPOLIS IN
46222-2147
US

V. Phone/Fax

Practice location:
  • Phone: 765-962-3800
  • Fax: 855-326-4293
Mailing address:
  • Phone: 317-924-1300
  • Fax: 317-924-3741

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001649
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: DR. LARRY S TAVEL
Title or Position: PRESIDENT
Credential: MD
Phone: 317-924-1300