Provider Demographics
NPI:1629360151
Name:SOUTH BEND OPTOMETRICS, LLC
Entity Type:Organization
Organization Name:SOUTH BEND OPTOMETRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:YAIR
Authorized Official - Middle Name:S
Authorized Official - Last Name:ELIAS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-386-2738
Mailing Address - Street 1:2933 CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1545
Mailing Address - Country:US
Mailing Address - Phone:574-386-2738
Mailing Address - Fax:
Practice Address - Street 1:2933 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-1545
Practice Address - Country:US
Practice Address - Phone:574-386-2738
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-02
Last Update Date:2011-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003629A152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty