Healthcare Provider Details

I. General information

NPI: 1538151592
Provider Name (Legal Business Name): FREEPORT OPTOMETRIC CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 02/17/2023
Certification Date: 02/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 W SOUTH ST
FREEPORT IL
61032-6777
US

IV. Provider business mailing address

980 W SOUTH ST
FREEPORT IL
61032-6777
US

V. Phone/Fax

Practice location:
  • Phone: 815-235-3466
  • Fax: 815-235-1712
Mailing address:
  • Phone: 815-235-3466
  • Fax: 815-235-1712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number46-7729
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number46-8516
License Number StateIL

VIII. Authorized Official

Name: LAVONNE M DOOLEY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 815-235-3466