Provider Demographics
NPI:1669876355
Name:LISLE FAMILY EYE CARE INC
Entity type:Organization
Organization Name:LISLE FAMILY EYE CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:LISLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-346-8500
Mailing Address - Street 1:747 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1044
Mailing Address - Country:US
Mailing Address - Phone:812-346-8500
Mailing Address - Fax:
Practice Address - Street 1:2580 MICHIGAN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-2491
Practice Address - Country:US
Practice Address - Phone:812-265-6222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2003353110CMedicaid
IN2003353110CMedicaid
4331560002Medicare NSC