Healthcare Provider Details

I. General information

NPI: 1750461257
Provider Name (Legal Business Name): VALAN S MAGNABOSCO O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 11/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5620 CRAWFORDSVILLE RD STE A
SPEEDWAY IN
46224-3726
US

IV. Provider business mailing address

1906 BROUGHTON ST
CARMEL IN
46032-7262
US

V. Phone/Fax

Practice location:
  • Phone: 317-243-5423
  • Fax: 317-243-5424
Mailing address:
  • Phone: 317-848-2566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18001889A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: