Provider Demographics
NPI:1043488778
Name:EYE CENTER GROUP LLC
Entity Type:Organization
Organization Name:EYE CENTER GROUP LLC
Other - Org Name:MORRISON EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DORIAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WINCONEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-286-8888
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47308-0472
Mailing Address - Country:US
Mailing Address - Phone:765-286-8888
Mailing Address - Fax:765-747-7962
Practice Address - Street 1:3631 N MORRISON RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5547
Practice Address - Country:US
Practice Address - Phone:765-286-8888
Practice Address - Fax:765-747-7962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-15
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100339260SMedicaid
IN100339260SMedicaid