Provider Demographics
NPI:1053973438
Name:LISLE FAMILY EYE CARE INC
Entity type:Organization
Organization Name:LISLE FAMILY EYE CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LISLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-352-6600
Mailing Address - Street 1:2580 MICHIGAN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-2492
Mailing Address - Country:US
Mailing Address - Phone:812-352-6600
Mailing Address - Fax:812-274-3116
Practice Address - Street 1:1125 MEDICAL PL
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2639
Practice Address - Country:US
Practice Address - Phone:812-522-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LISLE FAMILY EYE CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-05
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300027119Medicaid