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General NPI Number Information
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NPI Number | 1497125017
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Entity Type | Organization
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Legal Business Name | FAMILY FIRST VISION CARE INDIANA LLC
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Dates
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Enumeration Date | 09/25/2015
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Last Update Date | 04/28/2023
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Provider Practice Location Address
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Address Line | 4201 COLDWATER RD
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City | FORT WAYNE
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State | IN
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Zip | 46805-1113
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Country | US
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Telephone | 260-483-9568
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 631665
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City | CINCINNATI
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State | OH
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Zip | 45263-1665
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Country | US
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Telephone | 614-831-0268
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | NICOLE JANDERNAL
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Credential |
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Telephone | 732-236-7067
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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 |
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License Number State |
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