1104864115 NPI number — SITE VISION CENTER, PC

Table of content: (NPI 1104864115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104864115 NPI number — SITE VISION CENTER, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SITE VISION CENTER, 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:
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:
1104864115
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3236 BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUINCY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62301-3712
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-228-2060
Provider Business Mailing Address Fax Number:
217-228-2066

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3236 BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62301-3712
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-228-2060
Provider Business Practice Location Address Fax Number:
217-228-2066
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GIANFRIDDO
Authorized Official First Name:
RAYMOND
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
217-228-2060

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  0326000001 , 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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