=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720475965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN INDIANA EYE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2015
-----------------------------------------------------
Last Update Date | 04/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 488 W HOSPITAL RD
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47454-8807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-723-4752
-----------------------------------------------------
Fax | 812-723-4753
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 488 W HOSPITAL RD
-----------------------------------------------------
City | PAOLI
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47454-8807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-723-4752
-----------------------------------------------------
Fax | 812-723-4753
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPTOMETRIST
-----------------------------------------------------
Name | DR. ROBERT D COLE JR.
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 812-723-4752
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18003673A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------