=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780910497
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN C SIEGLTIZ
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2009
-----------------------------------------------------
Last Update Date | 10/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 W MAIN ST
-----------------------------------------------------
City | VEVAY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47043-1125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-427-2717
-----------------------------------------------------
Fax | 812-427-3265
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 96
-----------------------------------------------------
City | VEVAY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47043-0096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-427-2717
-----------------------------------------------------
Fax | 812-427-3265
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN C SIEGLTIZ
-----------------------------------------------------
Credential | O.D.
-----------------------------------------------------
Telephone | 812-427-2717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18003584A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18001358A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------