Provider Demographics
NPI:1467585885
Name:BOLING VISION CENTER, LLC
Entity Type:Organization
Organization Name:BOLING VISION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:CLAYTON
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:574-293-3545
Mailing Address - Street 1:2746 OLD US 20 W
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-1364
Mailing Address - Country:US
Mailing Address - Phone:574-293-3545
Mailing Address - Fax:574-522-0599
Practice Address - Street 1:1615 WINSTED DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-4696
Practice Address - Country:US
Practice Address - Phone:574-533-9633
Practice Address - Fax:574-533-9314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
5882560002Medicare NSC