MEDICARE: EYESITE-ILLINOIS VALLEY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046-008411	IL

General Provider Information

NPI Number	:	1477614329
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EYESITE-ILLINOIS VALLEY, LLC

Provider Business Mailing Address
First Line	:	215 RICHARD A MAUTINO DR
Second Line	:
City	:	SPRING VALLEY
State	:	IL
Zip	:	61362-1144
Country	:	US
Telephone Number	:	815-664-5331
Fax Number	:	815-663-5057

Provider Business Practice Location Address
First Line	:	215 RICHARD A MAUTINO DR
Second Line	:
City	:	SPRING VALLEY
State	:	IL
Zip	:	61362-1144
Country	:	US
Telephone Number	:	815-664-5331
Fax Number	:	815-663-5057

Authorized Official
Title or Position	:	OWNER
Name	:	KENT ALAN KUNKEL
Credential	:	OD
Telephone Number	:	815-664-5331

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	12/15/2020

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