Provider Demographics
NPI:1497797047
Name:INDIANA VISION CLINIC, INC
Entity Type:Organization
Organization Name:INDIANA VISION CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MILOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-288-2400
Mailing Address - Street 1:2004 EDISON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1712
Mailing Address - Country:US
Mailing Address - Phone:574-288-2400
Mailing Address - Fax:574-288-7132
Practice Address - Street 1:2004 EDISON RD
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46617-1712
Practice Address - Country:US
Practice Address - Phone:574-288-2400
Practice Address - Fax:574-288-7132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001593B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000273027OtherBLUE CROSS BLUE SHIELD
IN200380990Medicaid
IN01171OtherSPECTERA
IN200380990Medicaid
IN194030Medicare PIN
IN01171OtherSPECTERA
IN=========OtherVISION CARE PLAN