Provider Demographics
NPI:1689635831
Name:QUALITY OPTICAL INC
Entity Type:Organization
Organization Name:QUALITY OPTICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:FENWICK
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-825-3818
Mailing Address - Street 1:424 N MAIN ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MIDDLEBURY
Mailing Address - State:IN
Mailing Address - Zip Code:46540-8988
Mailing Address - Country:US
Mailing Address - Phone:574-825-3818
Mailing Address - Fax:574-825-9497
Practice Address - Street 1:424 N MAIN ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-8988
Practice Address - Country:US
Practice Address - Phone:574-825-3818
Practice Address - Fax:574-825-9497
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325370Medicaid
IN1074090001Medicare NSC
IN229280Medicare PIN