Provider Demographics
NPI:1770266322
Name:NORTHSIDE EYE CENTER LLC
Entity type:Organization
Organization Name:NORTHSIDE EYE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLOW
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-255-0654
Mailing Address - Street 1:9610 LIMA ROAD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-0104
Mailing Address - Country:US
Mailing Address - Phone:260-440-8388
Mailing Address - Fax:260-999-5645
Practice Address - Street 1:9610 LIMA ROAD
Practice Address - Street 2:SUITE 103
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9998
Practice Address - Country:US
Practice Address - Phone:260-440-8388
Practice Address - Fax:260-999-5645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-10
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty