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General NPI Number Information
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NPI Number | 1194267062
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Entity Type | Organization
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Legal Business Name | I-CARE BLOOMINGTON INC
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Dates
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Enumeration Date | 11/09/2016
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Last Update Date | 11/09/2016
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Provider Practice Location Address
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Address Line | 3205 W STATE ROAD 45
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City | BLOOMINGTON
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State | IN
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Zip | 47403-5107
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Country | US
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Telephone | 812-333-8912
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Fax | 812-333-8918
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Provider Business Mailing Address
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Address Line | 3818 W WOODYARD RD
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City | BLOOMINGTON
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State | IN
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Zip | 47404-1430
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Country | US
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Telephone | 812-325-3611
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Fax | 812-333-8918
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Authorized Official
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Title or Position | PRESIDENT
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Name | MARK A HOUSER
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Credential | O.D.
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Telephone | 812-325-3611
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18003478
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License Number State | IN
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