=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063686095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FEITZ EYE CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2008
-----------------------------------------------------
Last Update Date | 10/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 417 E COMMERCIAL AVE
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46356-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-696-2205
-----------------------------------------------------
Fax | 219-696-2205
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 417 E COMMERCIAL AVE
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46356-1814
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT A FEITZ
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 219-696-2205
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18002169B
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------