Healthcare Provider Details

I. General information

NPI: 1598114001
Provider Name (Legal Business Name): PEC ALTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 HOMER ADAMS PKWY
ALTON IL
62002-4856
US

IV. Provider business mailing address

2865 HOMER ADAMS PKWY
ALTON IL
62002-4856
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-1654
  • Fax: 618-465-8652
Mailing address:
  • Phone: 618-465-1654
  • Fax: 618-465-8652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: PAM HARK
Title or Position: INSURANCE SPECIALIST
Credential:
Phone: 618-234-3053