Healthcare Provider Details

I. General information

NPI: 1336246552
Provider Name (Legal Business Name): CHITTICK FAMILY EYE CARE LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1104 N VERMILION ST
DANVILLE IL
61832-3094
US

IV. Provider business mailing address

1104 N VERMILION ST
DANVILLE IL
61832-3094
US

V. Phone/Fax

Practice location:
  • Phone: 217-398-2020
  • Fax: 217-442-0119
Mailing address:
  • Phone: 217-398-2020
  • Fax: 217-442-0119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHAWN P MALLADY
Title or Position: PRESIDENT
Credential: OD
Phone: 508-837-3790