Healthcare Provider Details

I. General information

NPI: 1770856437
Provider Name (Legal Business Name): KERRY HEAD AND ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 02/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 TENNEY ST WAL-MART VISION CENTER
KEWANEE IL
61443-3702
US

IV. Provider business mailing address

730 TENNEY ST WAL-MART VISION CENTER
KEWANEE IL
61443-3702
US

V. Phone/Fax

Practice location:
  • Phone: 309-853-2302
  • Fax: 309-853-3015
Mailing address:
  • Phone: 309-853-2302
  • Fax: 309-853-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046008928
License Number StateIL

VIII. Authorized Official

Name: MR. KERRY H HEAD
Title or Position: OPTOMOTRIST
Credential: OD
Phone: 309-853-2302