Provider Demographics
NPI:1144650680
Name:MARION FAMILY OPTOMETRISTS, INC.
Entity type:Organization
Organization Name:MARION FAMILY OPTOMETRISTS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:260-563-0884
Mailing Address - Street 1:520 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WABASH
Mailing Address - State:IN
Mailing Address - Zip Code:46992-1415
Mailing Address - Country:US
Mailing Address - Phone:260-563-0884
Mailing Address - Fax:260-563-3284
Practice Address - Street 1:520 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992-1415
Practice Address - Country:US
Practice Address - Phone:260-563-0884
Practice Address - Fax:260-563-3284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-20
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001734152W00000X
IN18003449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100253710BMedicaid
IN068210Medicare UPIN