1063606978 NPI number — CLARKSON OPTOMETRY ILLINOIS PC

Table of content: (NPI 1063606978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063606978 NPI number — CLARKSON OPTOMETRY ILLINOIS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLARKSON OPTOMETRY ILLINOIS PC
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:
1063606978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 207163
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-7154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 CLINTONIAN PLAZA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BREESE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-200-4393
Provider Business Practice Location Address Fax Number:
618-526-7455
Provider Enumeration Date:
09/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WACHTER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CMO
Authorized Official Telephone Number:
636-200-4393

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  036104178 , 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)

  • Identifier: 036104178 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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