=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235300450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BORCHERT OPTOMETRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/15/2008
-----------------------------------------------------
Last Update Date | 05/07/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 273 W BROADWAY ST
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46176-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-398-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 273 W BROADWAY ST
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46176-1101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-398-8299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. GARY A BORCHERT
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 317-398-8299
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18002294
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------