Healthcare Provider Details

I. General information

NPI: 1447349873
Provider Name (Legal Business Name): MIDWEST VISION CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N MAIN ST SUITE 1
COLUMBIA IL
62236-1136
US

IV. Provider business mailing address

915 N MAIN STREET SUITE 1
COLUMBIA IL
62239
US

V. Phone/Fax

Practice location:
  • Phone: 618-281-2400
  • Fax:
Mailing address:
  • Phone: 618-281-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number
License Number StateIL

VIII. Authorized Official

Name: KELLY K KERKSICK
Title or Position: OPTOMETRIST
Credential: OD
Phone: 618-281-2400