=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467042549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EYE TO EYE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2021
-----------------------------------------------------
Last Update Date | 01/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2932 FRONTAGE RD
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46580-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-735-8559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 602 S COLFAX ST
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46580-4623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-735-8559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | MR. ROBERT TEETER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 181-532-5815
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------