Healthcare Provider Details

I. General information

NPI: 1376773598
Provider Name (Legal Business Name): PRAIRIE EYE CENTER LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 E MAIN ST
BEARDSTOWN IL
62618-1241
US

IV. Provider business mailing address

106 E MAIN ST
BEARDSTOWN IL
62618-1241
US

V. Phone/Fax

Practice location:
  • Phone: 217-323-1146
  • Fax: 217-323-1145
Mailing address:
  • Phone: 217-323-1146
  • Fax: 217-323-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number042000760
License Number StateIL

VIII. Authorized Official

Name: JASON LANG
Title or Position: BILLING ADMINISTRATOR
Credential:
Phone: 217-698-3030