Provider Demographics
NPI:1265883797
Name:PREVMED OPTOMETRY GROUP, PA
Entity type:Organization
Organization Name:PREVMED OPTOMETRY GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANACE
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-522-2054
Mailing Address - Street 1:1499 WINDHORST WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-8800
Mailing Address - Country:US
Mailing Address - Phone:317-522-2054
Mailing Address - Fax:855-671-4102
Practice Address - Street 1:2011 FLAGLER AVE
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-3732
Practice Address - Country:US
Practice Address - Phone:317-522-2054
Practice Address - Fax:855-671-4102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty