=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821059320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDIANA VISION DEVELOPMENT CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2006
-----------------------------------------------------
Last Update Date | 10/17/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10343 DAWSONS CREEK BLVD STE B BLDG 6
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46825-1906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-497-7973
-----------------------------------------------------
Fax | 260-497-7986
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10343 DAWSONS CREEK BLVD STE B BLDG 6
-----------------------------------------------------
City | FORT WAYNE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46825-1906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 260-497-7973
-----------------------------------------------------
Fax | 260-497-7986
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CARL O MYERS
-----------------------------------------------------
Credential | OD
-----------------------------------------------------
Telephone | 260-497-7973
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 18002177A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------