Provider Demographics
NPI:1932861713
Name:UNIVERSITY PARK VISION CENTER LLC
Entity Type:Organization
Organization Name:UNIVERSITY PARK VISION CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:REIDHAAR
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-471-2000
Mailing Address - Street 1:10723 KNOLLTON RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8746
Mailing Address - Country:US
Mailing Address - Phone:260-705-2285
Mailing Address - Fax:
Practice Address - Street 1:1221 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5887
Practice Address - Country:US
Practice Address - Phone:260-471-2000
Practice Address - Fax:260-471-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-09
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Multi-Specialty
No152WP0200XEye and Vision Services ProvidersOptometristPediatricsGroup - Multi-Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty