Provider Demographics
NPI:1457534125
Name:MARION FAMILY OPTOMETRISTS, INC.
Entity Type:Organization
Organization Name:MARION FAMILY OPTOMETRISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:E
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-662-6648
Mailing Address - Street 1:506 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-1961
Mailing Address - Country:US
Mailing Address - Phone:765-662-6648
Mailing Address - Fax:
Practice Address - Street 1:506 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-1961
Practice Address - Country:US
Practice Address - Phone:765-662-6648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001734B332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100253710AMedicaid
IN100253710BMedicaid
IN100253710BMedicaid
IN1156630001Medicare NSC
IN068210Medicare PIN