Provider Demographics
NPI:1508937855
Name:OPTOMETRIC ASSOCIATES OF SOUTH BEND
Entity Type:Organization
Organization Name:OPTOMETRIC ASSOCIATES OF SOUTH BEND
Other - Org Name:INSIGHT TOTAL FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORLAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-768-7721
Mailing Address - Street 1:350 S VAN BUREN ST
Mailing Address - Street 2:STE. 2B
Mailing Address - City:SHIPSHEWANA
Mailing Address - State:IN
Mailing Address - Zip Code:46565-9197
Mailing Address - Country:US
Mailing Address - Phone:260-768-7721
Mailing Address - Fax:260-768-7721
Practice Address - Street 1:350 S VAN BUREN ST
Practice Address - Street 2:STE. 2B
Practice Address - City:SHIPSHEWANA
Practice Address - State:IN
Practice Address - Zip Code:46565-9197
Practice Address - Country:US
Practice Address - Phone:260-768-7721
Practice Address - Fax:260-768-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2009-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0550260003Medicare NSC
IN193950Medicare PIN