Provider Demographics
NPI:1851484125
Name:DR TABITHA G TEMPLE PC
Entity Type:Organization
Organization Name:DR TABITHA G TEMPLE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:G
Authorized Official - Last Name:TEMPLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-267-3515
Mailing Address - Street 1:3505 N STATE ROAD 15
Mailing Address - Street 2:SUITE B
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46582-5503
Mailing Address - Country:US
Mailing Address - Phone:574-267-3515
Mailing Address - Fax:574-267-3259
Practice Address - Street 1:3505 N STATE ROAD 15
Practice Address - Street 2:SUITE B
Practice Address - City:WARSAW
Practice Address - State:IN
Practice Address - Zip Code:46582-5503
Practice Address - Country:US
Practice Address - Phone:574-267-3515
Practice Address - Fax:574-267-3259
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-01
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002882152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200388760AMedicaid
IN200388760AMedicaid
IN0573910001Medicare NSC