Healthcare Provider Details

I. General information

NPI: 1265436125
Provider Name (Legal Business Name): GROSSNICKLE EYE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 DUBOIS DR
WARSAW IN
46580-3212
US

IV. Provider business mailing address

2251 DUBOIS DR
WARSAW IN
46580-3212
US

V. Phone/Fax

Practice location:
  • Phone: 574-269-2777
  • Fax: 574-371-4697
Mailing address:
  • Phone: 574-269-2777
  • Fax: 574-371-4697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number50001530A
License Number StateIN

VIII. Authorized Official

Name: MATTHEW C RALSTIN
Title or Position: OWNER
Credential: M.D.
Phone: 574-269-2777