Provider Demographics
NPI:1730178831
Name:CITY OPTICAL CO., INC.
Entity type:Organization
Organization Name:CITY OPTICAL CO., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:S
Authorized Official - Last Name:TAVEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:317-924-1300
Mailing Address - Street 1:2839 LAFAYETTE RPAD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-2147
Mailing Address - Country:US
Mailing Address - Phone:317-924-1300
Mailing Address - Fax:317-924-9741
Practice Address - Street 1:3536 W 86TH STREET
Practice Address - Street 2:DR TAVEL FAMILY EYE CARE
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268-1992
Practice Address - Country:US
Practice Address - Phone:317-876-9611
Practice Address - Fax:317-924-9741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002621152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100364750AMedicaid
IN100364750Medicaid
IN0781680002Medicare NSC
IN100364750Medicaid