Healthcare Provider Details

I. General information

NPI: 1598720724
Provider Name (Legal Business Name): LORI A RICHARD OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LORI A SARVER OD

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 06/16/2020
Certification Date: 06/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

937 N 2ND ST
CHILLICOTHEE IL
61523-1823
US

IV. Provider business mailing address

937 N 2ND ST
CHILLICOTHEE IL
61523-1823
US

V. Phone/Fax

Practice location:
  • Phone: 309-274-6404
  • Fax: 309-274-6404
Mailing address:
  • Phone: 309-274-6404
  • Fax: 309-274-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008859
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: