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General NPI Number Information
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NPI Number | 1376914234
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Entity Type | Organization
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Legal Business Name | INVISTA OPTICAL, LLC
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Dates
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Enumeration Date | 10/16/2015
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Last Update Date | 12/07/2016
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Provider Practice Location Address
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Address Line | 640 E MICHIGAN ST STE B
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City | INDIANAPOLIS
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State | IN
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Zip | 46202-0007
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Country | US
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Telephone | 317-929-1401
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Fax | 317-929-1399
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Provider Business Mailing Address
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Address Line | 3416 ROYAL OAK DR
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City | INDIANAPOLIS
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State | IN
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Zip | 46227-7075
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Country | US
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Telephone | 765-346-0852
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Fax |
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Authorized Official
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Title or Position | OWNER/OPTOMETRIST
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Name | SAMANTHA JAHNKE
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Credential | OD
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Telephone | 765-346-0852
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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 | 18003798
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License Number State | IN
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