Healthcare Provider Details

I. General information

NPI: 1710971924
Provider Name (Legal Business Name): TABITHA G TEMPLE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date: 03/24/2006
Reactivation Date: 04/05/2006

III. Provider practice location address

2250 N POINTE DR
WARSAW IN
46582-9042
US

IV. Provider business mailing address

2250 N POINTE DR
WARSAW IN
46582-9042
US

V. Phone/Fax

Practice location:
  • Phone: 574-267-3515
  • Fax: 574-267-3259
Mailing address:
  • Phone: 574-267-3515
  • Fax: 574-267-3259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number18002882
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: