Provider Demographics
NPI:1760677058
Name:LOWELL OPTOMETRIC CENTER
Entity Type:Organization
Organization Name:LOWELL OPTOMETRIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WHITELEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:219-696-7191
Mailing Address - Street 1:303 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:IN
Mailing Address - Zip Code:46356-1711
Mailing Address - Country:US
Mailing Address - Phone:219-696-7191
Mailing Address - Fax:219-696-8551
Practice Address - Street 1:303 E MAIN ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:IN
Practice Address - Zip Code:46356-1711
Practice Address - Country:US
Practice Address - Phone:219-696-7191
Practice Address - Fax:219-696-8551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002511B332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN40391000001Medicare PIN