Provider Demographics
NPI:1508443474
Name:CITY OPTICAL CO., INC.
Entity Type:Organization
Organization Name:CITY OPTICAL CO., INC.
Other - Org Name:DR. TAVEL FAMILY EYE CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-924-1300
Mailing Address - Street 1:2839 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2147
Mailing Address - Country:US
Mailing Address - Phone:317-924-1300
Mailing Address - Fax:855-326-4293
Practice Address - Street 1:466 S INDIANA ST
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1710
Practice Address - Country:US
Practice Address - Phone:317-271-7296
Practice Address - Fax:855-326-4293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-26
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN197360OtherMEDICARE
IN300049976Medicaid