Healthcare Provider Details

I. General information

NPI: 1174667448
Provider Name (Legal Business Name): CENTER FOR SIGHT CENTRAL IL I SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 09/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 W HAY ST SUITE 311
DECATUR IL
62526-6328
US

IV. Provider business mailing address

304 W HAY ST SUITE 311
DECATUR IL
62526-6328
US

V. Phone/Fax

Practice location:
  • Phone: 217-877-5050
  • Fax: 217-877-9711
Mailing address:
  • Phone: 217-877-5050
  • Fax: 217-877-9711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008823
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036054803
License Number StateIL

VIII. Authorized Official

Name: DR. PHILLIP D ALWARD
Title or Position: OWNER
Credential: M.D.
Phone: 217-877-5050