Healthcare Provider Details

I. General information

NPI: 1053342410
Provider Name (Legal Business Name): STACEY BECK O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 SAGAMORE PKWY W
WEST LAFAYETTE IN
47906-1368
US

IV. Provider business mailing address

1601 NORTHWESTERN AVE
WEST LAFAYETTE IN
47906-2268
US

V. Phone/Fax

Practice location:
  • Phone: 765-743-3132
  • Fax: 765-743-2455
Mailing address:
  • Phone: 765-464-8573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number18003044B
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number18003044A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: