Provider Demographics
NPI:1831251800
Name:PRIVATE EYES VISION CENTER INC
Entity type:Organization
Organization Name:PRIVATE EYES VISION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPTICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:SHERRIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLAWSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNAO
Authorized Official - Phone:765-664-3633
Mailing Address - Street 1:1225 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952
Mailing Address - Country:US
Mailing Address - Phone:765-664-3633
Mailing Address - Fax:765-668-8933
Practice Address - Street 1:1225 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952
Practice Address - Country:US
Practice Address - Phone:765-664-3633
Practice Address - Fax:765-668-8933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0453890001Medicare ID - Type Unspecified