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General NPI Number Information
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NPI Number | 1700250628
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Entity Type | Organization
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Legal Business Name | SPORTS VISION SPECIALISTS LLC
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Dates
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Enumeration Date | 11/16/2015
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Last Update Date | 09/01/2020
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Provider Practice Location Address
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Address Line | 643 OHIO ST
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City | TERRE HAUTE
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State | IN
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Zip | 47807-3525
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Country | US
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Telephone | 812-232-1000
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Fax | 812-232-1007
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Provider Business Mailing Address
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Address Line | 643 OHIO ST
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City | TERRE HAUTE
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State | IN
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Zip | 47807-3525
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Country | US
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Telephone | 812-232-1000
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Fax | 812-232-1007
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA ELAINE JUDSON
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Credential | OD
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Telephone | 812-232-1000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152WS0006X
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Taxonomy Name | Sports Vision Optometrist
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License Number | 18003213A
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License Number State | IN
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