Healthcare Provider Details

I. General information

NPI: 1053303198
Provider Name (Legal Business Name): JACK T HEDRICK OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S MAIN ST
SALEM IN
47167-1040
US

IV. Provider business mailing address

600 S MAIN ST
SALEM IN
47167-1040
US

V. Phone/Fax

Practice location:
  • Phone: 812-883-2700
  • Fax: 812-883-2752
Mailing address:
  • Phone: 812-883-2700
  • Fax: 812-883-2752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001316A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: