Healthcare Provider Details

I. General information

NPI: 1649265570
Provider Name (Legal Business Name): AMEDCO INDIANA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2005
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CLEARVIEW DR.
VINCENNES IN
47591
US

IV. Provider business mailing address

2020 S CLEARVIEW DR
VINCENNES IN
47591-5576
US

V. Phone/Fax

Practice location:
  • Phone: 812-882-9600
  • Fax: 812-882-2944
Mailing address:
  • Phone: 812-882-9600
  • Fax: 812-882-2944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number01028066A
License Number StateIN

VIII. Authorized Official

Name: ERICA PERREIRA
Title or Position: COO
Credential:
Phone: 877-881-0022