Provider Demographics
NPI:1275081788
Name:LA PORTE CLINIC COMPANY LLC
Entity Type:Organization
Organization Name:LA PORTE CLINIC COMPANY LLC
Other - Org Name:LA PORTE PHYSICIAN NETWORK OPHTHALMOLOGY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-778-8076
Mailing Address - Street 1:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1300 STATE ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:LA PORTE
Practice Address - State:IN
Practice Address - Zip Code:46350-3185
Practice Address - Country:US
Practice Address - Phone:219-362-6297
Practice Address - Fax:219-324-3061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-13
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN152W00000X, 156F00000X, 207W00000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No156F00000XEye and Vision Services ProvidersTechnician/TechnologistGroup - Single Specialty
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty