Provider Demographics
NPI:1174647846
Name:DR KRISTINA MORRIS LLC
Entity Type:Organization
Organization Name:DR KRISTINA MORRIS LLC
Other - Org Name:DR KRISTINA MORRIS AND LITHIA JIMENEZ
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-332-3937
Mailing Address - Street 1:4619 W RICHLAND PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47404-9776
Mailing Address - Country:US
Mailing Address - Phone:812-332-3937
Mailing Address - Fax:812-336-7697
Practice Address - Street 1:4619 W RICHLAND PLAZA DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-9776
Practice Address - Country:US
Practice Address - Phone:812-332-3937
Practice Address - Fax:812-336-7697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002665B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200412960Medicaid
IN4934250001Medicare NSC
INU46960Medicare UPIN
INM100033254Medicare PIN