Provider Demographics
NPI:1205907540
Name:OPTOMETRIC ASSOCIATES OF SOUTH BEND
Entity type:Organization
Organization Name:OPTOMETRIC ASSOCIATES OF SOUTH BEND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORLAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-772-2012
Mailing Address - Street 1:1001 S EDGEWOOD DR
Mailing Address - Street 2:#5
Mailing Address - City:KNOX
Mailing Address - State:IN
Mailing Address - Zip Code:46534-8269
Mailing Address - Country:US
Mailing Address - Phone:574-772-2012
Mailing Address - Fax:574-772-2221
Practice Address - Street 1:1001 S EDGEWOOD DR
Practice Address - Street 2:#5
Practice Address - City:KNOX
Practice Address - State:IN
Practice Address - Zip Code:46534-8269
Practice Address - Country:US
Practice Address - Phone:574-772-2012
Practice Address - Fax:574-772-2221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0550260001Medicare NSC
IN760750Medicare ID - Type Unspecified