Provider Demographics
NPI:1497125017
Name:FAMILY FIRST VISION CARE INDIANA LLC
Entity Type:Organization
Organization Name:FAMILY FIRST VISION CARE INDIANA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:JANDERNAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-236-7067
Mailing Address - Street 1:PO BOX 631665
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-1665
Mailing Address - Country:US
Mailing Address - Phone:614-831-0268
Mailing Address - Fax:
Practice Address - Street 1:4201 COLDWATER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1113
Practice Address - Country:US
Practice Address - Phone:260-483-9568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty