Provider Demographics
NPI:1336280494
Name:KIM MOYER OD PC
Entity Type:Organization
Organization Name:KIM MOYER OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-866-5722
Mailing Address - Street 1:215 W KELLNER BLVD STE 12
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-2665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 W KELLNER BLVD STE 12
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2665
Practice Address - Country:US
Practice Address - Phone:219-866-5722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-10
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001961B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100210730CMedicaid
IN391050Medicare ID - Type UnspecifiedMEDICARE B