Provider Demographics
NPI:1659405983
Name:DR. POLLY HENDRICKS
Entity Type:Organization
Organization Name:DR. POLLY HENDRICKS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:POLLY
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:HENDRICKS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-288-8566
Mailing Address - Street 1:757 E LEWIS AND CLARK PKWY
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-2269
Mailing Address - Country:US
Mailing Address - Phone:812-288-8566
Mailing Address - Fax:812-284-2326
Practice Address - Street 1:757 E LEWIS AND CLARK PKWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2269
Practice Address - Country:US
Practice Address - Phone:812-288-8566
Practice Address - Fax:812-284-2326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002171152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN179620Medicare ID - Type Unspecified
INT69263Medicare UPIN