Provider Demographics
NPI:1487868071
Name:INDIAN MOUND EYE CLINIC INC
Entity Type:Organization
Organization Name:INDIAN MOUND EYE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:S
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:740-522-8444
Mailing Address - Street 1:604 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:OH
Mailing Address - Zip Code:43056-1204
Mailing Address - Country:US
Mailing Address - Phone:740-522-8444
Mailing Address - Fax:740-522-6493
Practice Address - Street 1:604 S 30TH ST
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:OH
Practice Address - Zip Code:43056-1204
Practice Address - Country:US
Practice Address - Phone:740-522-8444
Practice Address - Fax:740-522-6493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHIN9928081Medicare PIN
OH0250840001Medicare NSC
OHCB1441Medicare PIN