Provider Demographics
NPI:1942368733
Name:PLYMOUTH EYE CLINIC, P.C.
Entity Type:Organization
Organization Name:PLYMOUTH EYE CLINIC, P.C.
Other - Org Name:PLYMOUTH FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER (OPTOMETRIST)
Authorized Official - Prefix:DR
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-935-3937
Mailing Address - Street 1:2878 MILLER DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8094
Mailing Address - Country:US
Mailing Address - Phone:574-935-3937
Mailing Address - Fax:574-936-4942
Practice Address - Street 1:2878 MILLER DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8094
Practice Address - Country:US
Practice Address - Phone:574-935-3937
Practice Address - Fax:574-936-4942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002832152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200095640Medicaid
IN000000385395OtherANTHEM
IN200095640Medicaid
IN000000385395OtherANTHEM
INU63560Medicare UPIN