Provider Demographics
NPI:1750457198
Name:EYEWEAR BY DESIGN, LLC
Entity Type:Organization
Organization Name:EYEWEAR BY DESIGN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:MATTINGLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-423-4646
Mailing Address - Street 1:1410 UNION ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2060
Mailing Address - Country:US
Mailing Address - Phone:765-423-4646
Mailing Address - Fax:765-423-1149
Practice Address - Street 1:1410 UNION ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2060
Practice Address - Country:US
Practice Address - Phone:765-423-4646
Practice Address - Fax:765-423-1149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ6130OtherEYEMED