Provider Demographics
NPI:1083871297
Name:FAMILY VISION CLINIC PC
Entity Type:Organization
Organization Name:FAMILY VISION CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:COUTS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-842-3372
Mailing Address - Street 1:202 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-1516
Mailing Address - Country:US
Mailing Address - Phone:574-842-3372
Mailing Address - Fax:574-842-3390
Practice Address - Street 1:202 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511-1516
Practice Address - Country:US
Practice Address - Phone:574-842-3372
Practice Address - Fax:574-842-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002062332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100279120AMedicaid
IN100279120AMedicaid
IN512100Medicare UPIN