Healthcare Provider Details

I. General information

NPI: 1932378668
Provider Name (Legal Business Name): CHEN WEN Y
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MAIN ST
EAST ALTON IL
62024-1173
US

IV. Provider business mailing address

200 W MAIN ST
EAST ALTON IL
62024-1173
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-0440
  • Fax:
Mailing address:
  • Phone: 618-259-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number StateIL

VIII. Authorized Official

Name: WEN Y CHEN
Title or Position: MD
Credential:
Phone: 618-259-0440