MEDICARE: CITY OPTICAL CO., INC.

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	01022315	IN
2	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1912996091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OPTICAL CO., INC.

Provider Business Mailing Address
First Line	:	2839 LAFAYETTE ROAD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46222-2147
Country	:	US
Telephone Number	:	317-924-1300
Fax Number	:	317-924-3741

Provider Business Practice Location Address
First Line	:	1164 S 17TH STREET
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-1901
Country	:	US
Telephone Number	:	765-457-5384
Fax Number	:	317-924-3741

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LARRY S TAVEL
Credential	:	MD
Telephone Number	:	317-924-1300

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	11/04/2024

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Directions to “CITY OPTICAL CO., INC. ” Practice Location

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