Provider Demographics
NPI:1841215738
Name:NORTHERN INDIANA OPTOMETRISTS, PC
Entity Type:Organization
Organization Name:NORTHERN INDIANA OPTOMETRISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:PESCHKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:574-291-9200
Mailing Address - Street 1:4123 S MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2545
Mailing Address - Country:US
Mailing Address - Phone:574-291-9200
Mailing Address - Fax:574-299-4423
Practice Address - Street 1:4123 S MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2545
Practice Address - Country:US
Practice Address - Phone:574-291-9200
Practice Address - Fax:574-299-4423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-13
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1548296718OtherINDIVIDUAL NPI
IN200831530Medicaid
IN200831530Medicaid