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General NPI Number Information
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NPI Number | 1972513653
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Entity Type | Organization
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Legal Business Name | DEBOER OD LTD
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 12/29/2011
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Provider Practice Location Address
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Address Line | 609 N HALLECK ST
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City | DEMOTTE
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State | IN
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Zip | 46310-9545
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Country | US
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Telephone | 219-987-3673
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 849 609 N. HALLECK STREET
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City | DEMOTTE
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State | IN
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Zip | 46310-0849
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Country | US
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Telephone | 219-987-3673
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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. TIMOTHY J DEBOER
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Credential | OD
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Telephone | 219-987-3673
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 18002342
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License Number State | IN
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