Healthcare Provider Details

I. General information

NPI: 1396940938
Provider Name (Legal Business Name): MARENGO VISION CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 N DIVISION ST
HARVARD IL
60033-3060
US

IV. Provider business mailing address

313 N DIVISION ST
HARVARD IL
60033-3060
US

V. Phone/Fax

Practice location:
  • Phone: 815-943-6635
  • Fax:
Mailing address:
  • Phone: 815-943-6635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009334
License Number StateIL

VIII. Authorized Official

Name: DR. MICHAEL W. THOMAS
Title or Position: PRESIDENT
Credential: O.D.
Phone: 815-568-6508