=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013905827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA EYE CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2005
-----------------------------------------------------
Last Update Date | 02/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 N EMERSON AVE
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46143-8895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-881-3937
-----------------------------------------------------
Fax | 317-887-4008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 N EMERSON AVE
-----------------------------------------------------
City | GREENWOOD
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46143-8895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-881-3937
-----------------------------------------------------
Fax | 317-887-4008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CAROL SCHLARB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-881-3937
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------