Provider Demographics
NPI:1821596271
Name:GOOTEE VISION CENTER, LLC
Entity Type:Organization
Organization Name:GOOTEE VISION CENTER, LLC
Other - Org Name:BROWN COUNTY EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOOTEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:317-439-9396
Mailing Address - Street 1:50 WILLOW ST STE A
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47448-7063
Mailing Address - Country:US
Mailing Address - Phone:812-988-4937
Mailing Address - Fax:
Practice Address - Street 1:50 WILLOW ST STE A
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IN
Practice Address - Zip Code:47448-7063
Practice Address - Country:US
Practice Address - Phone:812-988-4937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18004070B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ024656Medicaid