Provider Demographics
NPI:1801845995
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:574-936-9137
Mailing Address - Street 1:313 E JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1825
Mailing Address - Country:US
Mailing Address - Phone:574-936-9136
Mailing Address - Fax:574-936-9146
Practice Address - Street 1:313 E JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1825
Practice Address - Country:US
Practice Address - Phone:574-936-9136
Practice Address - Fax:574-936-9146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100325370Medicaid
IN1074090002Medicare NSC
IN100325370Medicaid
IN229280Medicare PIN