Provider Demographics
NPI:1912098229
Name:PROFESSIONAL VISION INC
Entity Type:Organization
Organization Name:PROFESSIONAL VISION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SNYDER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:574-234-7600
Mailing Address - Street 1:17615 STATE ROAD 23
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1718
Mailing Address - Country:US
Mailing Address - Phone:574-234-7600
Mailing Address - Fax:574-234-8408
Practice Address - Street 1:17615 STATE ROAD 23
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1718
Practice Address - Country:US
Practice Address - Phone:574-234-7600
Practice Address - Fax:574-234-8408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001393152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000105030OtherANTHEM
IN000000105030OtherANTHEM