Provider Demographics
NPI:1376652933
Name:VANARSDALL FAMILY OPTOMETRY P C
Entity type:Organization
Organization Name:VANARSDALL FAMILY OPTOMETRY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VANARSDALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:812-376-3068
Mailing Address - Street 1:1033 JACKSON ST STE C
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-5769
Mailing Address - Country:US
Mailing Address - Phone:812-376-3068
Mailing Address - Fax:812-376-6771
Practice Address - Street 1:1033 JACKSON ST STE C
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5769
Practice Address - Country:US
Practice Address - Phone:812-376-3068
Practice Address - Fax:812-376-6771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN56000172A152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100083400AMedicaid
IN22000000103899OtherANTHEM
IN56000172AOtherLICENSE REGISTRATION NUM
IN22000000103899OtherANTHEM
IN56000172AOtherLICENSE REGISTRATION NUM
IN56000172AOtherLICENSE REGISTRATION NUM
IN=========OtherTRICARE