MEDICARE: EYECARE INDIANA II, PC

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	:	1689925505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYECARE INDIANA II, PC

Provider Business Mailing Address
First Line	:	4121 S MICHIGAN ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-2545
Country	:	US
Telephone Number	:	574-291-9200
Fax Number	:	574-299-4423

Provider Business Practice Location Address
First Line	:	1919 E MARKLAND AVE
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46901-6237
Country	:	US
Telephone Number	:	765-459-8182
Fax Number	:	765-459-5550

Authorized Official
Title or Position	:	COO
Name	:	TERRI PESCHKE
Credential	:
Telephone Number	:	574-291-9200

Provider Enumeration Date	:	10/02/2012
Last Update Date	:	11/16/2012

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