1336265875 NPI number — CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD

Table of content: (NPI 1336265875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336265875 NPI number — CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL ILLINOIS OPTOMETRIC ASSOCIATES LTD
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:
1336265875
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 N SPRINGFIELD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIRDEN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62690-1455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-965-3306
Provider Business Mailing Address Fax Number:
217-965-3679

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 N SPRINGFIELD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIRDEN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62690-1455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-965-3306
Provider Business Practice Location Address Fax Number:
217-965-3679
Provider Enumeration Date:
03/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEDRICK
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
217-965-3306

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  046008125 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 152W00000X , with the licence number: 046006408 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 410042503 . This is a "HEDRICK RAILRAOD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 046006408 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0001115000 . This is a "BC BS GROUP NUMBER" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 046008125 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 410042688 . This is a "RUBRICH RAILRAOD MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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