Provider Demographics
NPI:1710997044
Name:INDIANA VISION CLINIC, INC
Entity Type:Organization
Organization Name:INDIANA VISION CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:MILOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-266-5470
Mailing Address - Street 1:2730A CASSOPOLIS ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-5102
Mailing Address - Country:US
Mailing Address - Phone:574-266-5470
Mailing Address - Fax:574-264-3081
Practice Address - Street 1:2730A CASSOPOLIS ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-5102
Practice Address - Country:US
Practice Address - Phone:574-266-5470
Practice Address - Fax:574-264-3081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001593A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000273028OtherBCBS ELKHART GROUP
IN200380990BMedicaid
IN2550910002OtherDURABLE MEDICAL EQUIP
IN000000273028OtherBCBS ELKHART GROUP
IN2550910002Medicare NSC
IN194030Medicare PIN