Provider Demographics
NPI:1639347743
Name:CHARLES H. RUTAN, O.D.
Entity Type:Organization
Organization Name:CHARLES H. RUTAN, O.D.
Other - Org Name:ADVANTAGE EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / OPTOMETRIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:HUGH
Authorized Official - Last Name:RUTAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-832-3292
Mailing Address - Street 1:224 ELM ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-2312
Mailing Address - Country:US
Mailing Address - Phone:765-832-3292
Mailing Address - Fax:765-832-9730
Practice Address - Street 1:224 ELM ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-2312
Practice Address - Country:US
Practice Address - Phone:765-832-3292
Practice Address - Fax:765-832-9730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002266A332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100243930Medicaid
IN100243930Medicaid