Provider Demographics
NPI:1902944325
Name:FAMILY EYE CARE OF SOUTH BEND
Entity Type:Organization
Organization Name:FAMILY EYE CARE OF SOUTH BEND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:PROUDFIT
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:1574-289-3937
Mailing Address - Street 1:220 N IRONWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-2518
Mailing Address - Country:US
Mailing Address - Phone:157-428-7088
Mailing Address - Fax:157-428-0735
Practice Address - Street 1:220 NORTH IRONWOOD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46615-1623
Practice Address - Country:US
Practice Address - Phone:157-428-7088
Practice Address - Fax:157-428-7895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001502B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0205890001OtherDEMARC
IN251850AOtherMEDICARE ID
INT35012Medicare UPIN