Healthcare Provider Details

I. General information

NPI: 1578766515
Provider Name (Legal Business Name): PRAIRIE EYE CENTER, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 W MORTON AVE
JACKSONVILLE IL
62650-2623
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-7015
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-6814
  • Fax: 217-245-0375
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-4728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036-051855
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State

VIII. Authorized Official

Name: JASON LANG
Title or Position: BILLING ADMINISTRATOR
Credential:
Phone: 217-698-3030