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General NPI Number Information
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NPI Number | 1912189507
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Entity Type | Organization
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Legal Business Name | BARRY J CLOSE OD, INC.
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Dates
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Enumeration Date | 12/05/2007
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Last Update Date | 03/17/2008
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Provider Practice Location Address
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Address Line | 2821 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46805-4732
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Country | US
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Telephone | 260-482-9514
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Fax |
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Provider Business Mailing Address
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Address Line | 2821 E STATE BLVD
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City | FORT WAYNE
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State | IN
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Zip | 46805-4732
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Country | US
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Telephone | 260-482-9514
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. BARRY JOSEPH CLOSE
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Credential | OD
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Telephone | 260-482-9514
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332H00000X
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Taxonomy Name | Eyewear Supplier
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License Number | 18001912
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License Number State | IN
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