Provider Demographics
NPI:1972134609
Name:WALLY EYE CENTER PC
Entity Type:Organization
Organization Name:WALLY EYE CENTER PC
Other - Org Name:ANGIE EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-320-5406
Mailing Address - Street 1:2531 W ELROD LN
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IN
Mailing Address - Zip Code:47167-9405
Mailing Address - Country:US
Mailing Address - Phone:812-320-5406
Mailing Address - Fax:812-288-8466
Practice Address - Street 1:1351 VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-7747
Practice Address - Country:US
Practice Address - Phone:812-288-8458
Practice Address - Fax:812-288-8466
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-31
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty