1053852020 NPI number — CENTRAL ILLINOIS FAMILY EYECARE LLC

Table of content: (NPI 1053852020)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053852020 NPI number — CENTRAL ILLINOIS FAMILY EYECARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL ILLINOIS FAMILY EYECARE LLC
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:
6
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:
1053852020
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7815 N KNOXVILLE AVE STE 1A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61614-2022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
309-839-1614
Provider Business Mailing Address Fax Number:
309-839-8874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4203 N SHERIDAN RD
Provider Second Line Business Practice Location Address:
STE A1-4
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61614-7170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
309-686-0763
Provider Business Practice Location Address Fax Number:
309-685-8809
Provider Enumeration Date:
03/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BRTVA
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
309-686-0763

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046-007731 , 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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