Provider Demographics
NPI:1376914234
Name:INVISTA OPTICAL, LLC
Entity Type:Organization
Organization Name:INVISTA OPTICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAHNKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-346-0852
Mailing Address - Street 1:3416 ROYAL OAK DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7075
Mailing Address - Country:US
Mailing Address - Phone:765-346-0852
Mailing Address - Fax:
Practice Address - Street 1:640 E MICHIGAN ST STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-0007
Practice Address - Country:US
Practice Address - Phone:317-929-1401
Practice Address - Fax:317-929-1399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201205510Medicaid
IN197360006Medicare PIN
ININ2938Medicare PIN