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General NPI Number Information
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NPI Number | 1104989011
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Entity Type | Organization
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Legal Business Name | INDIANA NEURO-OPHTHALMOLOGY & CENTER FOR BALANCE
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Dates
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Enumeration Date | 12/19/2006
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Last Update Date | 10/02/2019
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Provider Practice Location Address
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Address Line | 3721 ROME DR SUITE A
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City | LAFAYETTE
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State | IN
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Zip | 47905-4408
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Country | US
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Telephone | 765-807-7100
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Fax | 765-807-7101
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Provider Business Mailing Address
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Address Line | 3721 ROME DR SUITE A
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City | LAFAYETTE
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State | IN
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Zip | 47905-4408
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Country | US
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Telephone | 765-807-7100
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Fax | 765-807-7101
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Authorized Official
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Title or Position | PRESIDENT
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Name | SCOTT SANDERS
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Credential | MD
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Telephone | 765-807-7100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number | 01045654
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License Number State | IN
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