MEDICARE: NORTHEAST FAMILY EYECARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist

General Provider Information

NPI Number	:	1275103731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEAST FAMILY EYECARE, LLC

Provider Business Mailing Address
First Line	:	2821 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4732
Country	:	US
Telephone Number	:	260-482-9514
Fax Number	:	260-203-5391

Provider Business Practice Location Address
First Line	:	2821 E STATE BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-4732
Country	:	US
Telephone Number	:	260-482-9514
Fax Number	:	260-203-5391

Authorized Official
Title or Position	:	OWNER
Name	:	KATHRYN ZACHMAN
Credential	:	O.D.
Telephone Number	:	260-482-9514

Provider Enumeration Date	:	06/28/2021
Last Update Date	:	06/30/2021

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