1891820312 NPI number — MAPLESHADE VISION CENTER INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891820312 NPI number — MAPLESHADE VISION CENTER INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAPLESHADE VISION CENTER INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891820312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11825 STATE ROUTE 40
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
DUNLAP
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61525-8842
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-243-5900
Provider Business Mailing Address Fax Number:
309-243-9852

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11825 STATE ROUTE 40
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
DUNLAP
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61525-8842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-243-5900
Provider Business Practice Location Address Fax Number:
309-243-9852
Provider Enumeration Date:
02/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MOUSHON
Authorized Official First Name:
GAYLAN
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-243-5900

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  0460088755 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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