Provider Demographics
NPI:1144462235
Name:EYE ASSOCIATES GROUP, LLC
Entity type:Organization
Organization Name:EYE ASSOCIATES GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:765-348-2020
Mailing Address - Street 1:6208 CONSTITUTION DR STE B
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-1585
Mailing Address - Country:US
Mailing Address - Phone:260-432-0575
Mailing Address - Fax:260-432-0835
Practice Address - Street 1:6208 CONSTITUTION DR STE B
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1585
Practice Address - Country:US
Practice Address - Phone:260-432-0575
Practice Address - Fax:260-432-0835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-03
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200005400Medicaid
IN1046420005Medicare NSC
IN668170Medicare PIN